Cutting among Adolescents aka Selfinjury

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Cutting among Adolescentsaka Self-injury

• Zena Edwards
• Michael Varady
• June 10, 2005

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What do these people have in common?

• Angelina Jolie
• Christina Ricci
• Courtney Love
• Princess Diana

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Promoting The Cutting Culture

• Websites-Blood Red
• -Razor Blade Kisses
• -The Cutting World
• Films- Thirteen
• Genre of music- emo

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It is NOT self-injury if your primary purpose is

• Sexual pleasure
• Body decoration
• Spiritual enlightenment via ritual
• Fitting in or being cool
• Attempting suicide

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Terms for self-injury

• Self-inflicted violence
• Self-mutilation
• Self-abuse

• Self-injury
• Self-harm
• Parasuicide
• Delicate cutting

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Instruments/Methods

• Burning (35)
• Cutting, scratching (72)
• Hitting your body with an object or your fists
  (35)
• Hitting a heavy object (like a wall)
• Picking at skin or scab until it bleeds (22)
• Biting yourself
• Pulling your hair out (10)
• Inserting objects in body openings
• Bruising or breaking bones (8)

• Knives
• Razors
• Glass
• Pins
• Any sharp object

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Areas most typically injured

• Arms and wrists
• Legs
• Abdomen
• Head
• Chest
• Genitals

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What do self-Injurers say about ..Why they do
it?

• 'to run away from my feelings'
• 'to feel pain on the outside instead of the
  inside'
• 'to cope with my feelings'
• 'to express my anger toward myself'
• 'to feel like I'm real'
• 'to turn off emotions and hide from reality'
• 'to tell people that I need help'
• 'to get people's attention'
• 'to tell people I need to be in hospital'
• 'to get people to care about me'
• 'to make other people feel guilty'
• 'to drive people away'
• 'to get away from stress and responsibility'
• 'to manipulate situations or people'

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Definition

• Self-injury is the act of attempting to alter a
  mood state by inflicting physical harm serious
  enough to cause tissue damage to the body.
• Usually deliberate, repetitive, impulsive, and
  non-lethal
• Tissue damage refers to damage that tears,
  bruises, or burns the skin something that causes
  bleeding or marks that dont go away in a few
  minutes.

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DSM IV-TR

• No formal classification
• Self-injury behavior is seen in connection with a
  number of diagnosis
• Borderline Personality Disorder
• Depression
• Eating Disorders (anorexia and bulimia)
• Obsessive-Compulsive Disorders (OCD)
• Post-Traumatic Stress Disorder (PTSD)
• Dissociative Disorders
• Anxiety and Panic Disorders
• Impulse Disorder Not Otherwise Specified

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Overall picture of Self-injurer

• Person who strongly dislikes/invalidates oneself,
  low self-esteem
• Are hypersensitive to rejection
• Chronically angry, usually at themselves, tend to
  suppress their anger, high levels of aggressive
  feelings which they disapprove of strongly and
  which are suppressed or directed inward
• More impulsive, lacking in impulse control, act
  in accordance with their mood of the moment
• Tend not to plan for future

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Picture cont

• Depressed and suicidal/self-destructive
• Suffer chronic anxiety
• Tend toward irritability
• Do not see themselves as skilled in coping
• Do not have a flexible repertoire of coping
  skills
• Do not think they have much control over
  how/whether they cope with life
• Tend to be avoidant
• Do not see themselves as empowered

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Incident and Onset

• 12 to 14 of adolescents reported self-injury
  behavior
• 40 to 61 in adolescent inpatient settings
• (Ross Heath, 2002)
• Higher proportion of females (64) than males
  (36)
• 750 per 100,000- general population
• Typical onset-puberty
• Persist for five to ten years or longer

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Key Emotional Motivators

• Anger/frustration/rage- (68)
• Fear- (36)
• Self-hatred- (32)
• Desperation/despair- (27)

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Warning Signs

• Unexplained frequent injuries, including cuts and
  burns
• Wearing long pants and sleeves in warm weather
• Low self-esteem
• Difficulty handling feelings
• Poor functioning at work, school or home
• Relationship problems

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Predictors

• Past trauma/invalidation
• Van der Kolk, Perry, and Herman (1991)
• Exposure to physical or sexual abuse
• Physical or emotional neglect
• Chaotic family conditions during childhood,
  latency, and adolescence
• Invalidation independent of abuse
• Linehan (1993a)
• invalidating environments one in which
  communication of private experiences is met by
  erratic, inappropriate, or extreme responses

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Invalidation cont.

• Two primary characteristics
• Tells the individual that they are wrong both in
  their description and analysis of of their own
  experiences, especially as to what is causing
  emotions, beliefs, and actions
• Attributes ones experiences to socially
  unacceptable characteristics or personality
  traits

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Forms of invalidation

• Youre angry but you just wont admit it
• You say no but you mean yes, I know
• You really did do (something you in truth
  hadnt). Stop lying
• Youre being hypersensitive
• Youre just lazy
• I wont let you manipulate me like that
• Cheer up. Snap out of it. You can get over this
• If youd just look on the bright side and stop
  being a pessimist
• Youre just not trying hard enough
• Ill give you something to cry about

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Predictors

• Biological/Neurochemistry
• Carlson (1986)
• Reduced levels of serotonin increase in
  endorphin rush
• Decreases in necessary brain neurotransmitters
• Behaviorists
• Operant conditioning
• Positively reinforced by getting attention and
  repeat self-harming act
• The sensory stimulation associated with self-harm
  serves as a positive reinforcer and stimulus for
  further abuse
• Sensory Contingencies
• Attempting to mediate levels of sensory arousal
  (increase or mask sensory input)
• Release of physiological tension/arousal

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Therapeutic Approaches

• Dialectical Behavioral Therapy (BPD)
• Interpersonal Group Therapy (BPD)
• The CPTSD Approach (non-BPD)
• Rational-Emotive Therapy (non-BPD)
• Psychopharmacological
• Hypnosis and relaxation
• Hospital-based treatment

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Dialectical Behavioral Therapy

• Dialectical Behavioral Therapy (DBT) consists of
  two parts
• Once-weekly psychotherapy sessions in which a
  particular problematic behavior or event from the
  past week is explored in detail, beginning with
  the chain of events leading up to it, going
  through alternative solutions that might have
  been used, and examining what kept the client
  from using more adaptive solutions to the
  problemBoth between and during sessions, the
  therapist actively teaches and reinforces
  adaptive behaviors, especially as they occur
  within the therapeutic relationship.
• Weekly 2.5-hour group therapy sessions in which
  interpersonal effectiveness, distress
  tolerance/reality acceptance skills, emotion
  regulation, and mindfulness skills are taught.
  Group therapists are not available over the phone
  between sessions they refer patients in crisis
  to the individual therapist.

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Interpersonal Group Therapy

• time-limited group psychotherapy
• a Rogerian, client-centered facilitation style.
  Group disagreements and disappointments with the
  therapists or other group members are worked out
  within the group by clients, with the therapists
  intervening only when the process of therapy
  seems to be getting off-track ("derailing").
• Therapist interventions are intended to be
  tentative, exploratory, indirect, and neutral.
  Two-sided commentary, reiteration/paraphrasing,
  reflecting doubt/confusion, answering of
  enquiries, and supportive statements are part of
  the IPG model.

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The CPTSD Approach

• three stages establishing safety, remembrance
  and mourning for what was lost, and reconnecting
  to society.
• name the problem- acknowledging the trauma and
  its past and present effects, both mental and
  physical.
• restore a sense of control to the client.
• establishing a safe environment setting up
  support networks of caring people, helping the
  client to protect him/herself from any physical
  danger they may face, and developing a plan for
  dealing with for future protection, one that
  takes into account any self-destructive behaviors
  the client engages in.
• Even after these steps are complete, the trauma
  may never be fully resolved recovery is to be a
  lifelong process. However, at this point, it
  becomes on of many factors in a client's life and
  not the dominant one.

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Rational-Emotive Therapy

• Doesn't directly address self-harm as an issue,
  its precepts can be helpful in controlling the
  sometimes uncontrollable rage self-injurers feel.
  
• Rational-Emotive therapy was developed by Albert
  Ellis
• your feelings don't control your thoughts -- your
  thoughts control your feelings.
• Negative emotions are not inevitable, but come
  about as the result of patterns of thinking we've
  laid down over the years.
• If we can learn to rethink the situations, we can
  learn to control negative emotions.

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Psychopharmacological Approaches

• Neurotransmitters are chemicals used to transmit
  messages in the brain.
• Different neurotransmitter receptors affect
  different bodily functions. These receptors are
  involved in regulating emotion, mood,
  impulsivity, aggression, digestion, smooth muscle
  relaxation, and sexual behavior, among other
  functions.
• Three sorts of neurotransmitters have been of
  concern to scientists studying self-injurious
  behavior serotonin, dopamine, and endorphins.
  The strongest evidence so far points to
  serotonergic deficits -- the brain does not have
  enough serotonin available for use.
• The theory is that self-mutilation releases
  endorphins and over time, the body becomes
  addicted to these pain-relieving
  neurotransmitters. The impulse to self-injure
  arises from a craving for endorphins.

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Psychopharmacological drugs

• Probably the most investigated drugs for SIB are
  naltrexone and naloxone, opiate antagonists.
• The new class of atypical neuroleptics, which
  tend to bind to dopamine and serotonin receptors,
  seem to show some promise in treating SIB as
  well.
• Clozapine has been reported to reduce SIB in
  personality disordered subjects
• These drugs can also have troublesome side
  effects -- patients on clozapine, for example,
  require weekly blood tests because of the risk of
  white-blood-cell abnormalities.

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Hypnosis and relaxation

• Hypnotic relaxation techniques have apparently
  been used, with some success, as an adjunct to
  therapy.
• three types of hypnosis
• Breath counting the patient is led into a trance
  and instructed to notice her breathing, counting
  each deep slow breath.
• Positive imagery the patient is put into a
  trance state and instructed to visualize herself
  in a calm, pleasant, relaxing place doing
  something she enjoys. This image is held for a
  while.
• Affect bridge after trance is achieved, the
  patient is asked to use the current unpleasant
  feelings to remember other times in his life when
  he's felt this way. Memories that are too
  distressing to talk about in a normal state are
  sometimes speakable in a trance state.

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Hospital-based treatment

• SAFE Alternatives (1-800-DONTCUT) is an inpatient
  program specifically for self-injurers located at
  MacNeal Hospital in a Chicago suburb
• The program combines milieu therapy,
  cognitive-behavioral therapies, and group and
  individual exercises to help patients gain an
  awareness of why they hurt themselves and how to
  stop.
• They claim to be the only inpatient unit for
  self-injurers in the U.S.
• The Sanctuary at Friends' Hospital in
  Philadelphia is an inpatient unit for trauma
  survivors that is aware of the special needs of
  self-injurers and takes them into account in its
  treatment program.
• Butler Hospital in Rhode Island offers a partial
  hospitalization program that uses dialectical
  behavioral therapy to treat a diverse patient
  population of self-injurers.

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What Helps/Hinders healing from self-injury

• Helpful
• Unconditional acceptance and compassion
• A non-judgmental attitude
• Trust and reliability
• Kindness, caring, honesty
• Empathy, warmth, genuineness
• Active listening
• Being treated with firmness/gentleness
• Confidential and safe setting
• Being trusted to take care of ones own wounds
• support and space to explore difficult issues
• Gaining self-awareness and insight into the
  thought processes
• Revealing scars for the first time
• Being listened to, believed, taken seriously,
  feeling understood
• Feeling safe to cry and express feelings
• Developing healthier coping strategies

• Unhelpful
• A dictatorial, arrogant and judgmental approach
• Denying the problem exists
• Lack of continuity
• Deeply engrained issues not being addressed
• Sympathy
• Personal prejudice
• Not being heard
• Preconceived ideas/stereotyping
• Being left alone to cope with the aftermath
• No self-harming contracts
• Being labeled
• Too much too soon-probing into where a client is
  not ready to go

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What is a School Counselor to do?

• Primary goal- create a safe environment
• Foster a strong alliance with the student
• Emphasis on structure, consistency, and
  predictability that is modeled in counseling
• Developing a detailed safety plan with the
  student that emphasizes the students taking
  responsibility for behaviors
• identifying self-injury triggers, physical cues,
  and reducers related to self-injury
• Exploring safe people/places to go when wanting
  to self-injure
• Deliberate avoidance of objects that can be used
  to self-injure

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School Counselor cont

• Techniques to help students manage self-injurious
  impulses
• Increasing feeling awareness and recognition
• Increasing coping skills to be used in managing
  feelings
• Encouraging the use of self-soothing techniques
  such as relaxation exercises
• Encouraging the use of safe places

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Cessation factors of self-injury behavior

• Developing an ability to identify and express
  feelings verbally
• Learning to use behavioral alternatives to
  self-injury
• Development of impulse control
• Sense of control in managing the self-injurious
  behaviors
• Self-harm is rarely done when others are nearby

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Caveat for School Counselors

• Possibility of accidental death as a result of
  damage inflicted on the body
• Important to assess a students self-injury
• Severity of the behaviors (severe chronic)
• Possible medical complications (infections)
• Issues related to suicide
• Assessment of depression, helplessness,
  hopelessness
• Suicide ideation, plan and intent, preparation
  and access to means, past attempts
• Social support
• Family history
• Recent stressors

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Referral Issues

• The role of the school counselor is intervention
  and prevention NOT diagnosis and treatment
• Make a referral for inpatient or out-patient
  treatment
• Be knowledgeable of practitioners and treatment
  centers that have specific training in the
  management of self-injury
• Continue to play a role in the students
  treatment process if appropriate
• Safe person the student can talk to
• Arranging home tutoring/collaborating with the
  educational tutor at the residential center or
  hospital
• Advocate for students
• Faculty in-services
• Parenting groups
• Classroom guidance on self-injury

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Examples of Self-injury

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Be with me please

• Can I trust you with my pain?
• To treat it with kindness and respect?
• To listen to it,
• So I can speak the unspoken?
• If I entrust you with my grief,
• Will you help me take care of it?
• Console it? Soothe it? Make it feel safe?
• Will you accept it as a gift to be protected?
• I feel my need and I fear it,
• As I fear all that I do not understand,
• Yet I ask you to be with me,
• For I am tired of walking alone

• Will you help me catch my tears
• As the floodgates open?
• Swim with me into the unknown?
• Save me from drowning in my sorrow?
• If I take the risk and end the drought,
• Will you leave me alone and sodden after the
  storm?
• Will you reach for your umbrella,
• And just walk away?

Source Healing the Hurt Within Understand and
relieve the Suffering behind self-behavior, Jan
Sutton
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• HealthyPlace. Who self-injures Psychological
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• approach to working with adolescent females.
  Journal of Mental Health Counseling, 25 (2),
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• injure Implications and strategies for school
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