Self-Injurious Behavior in Adolescents

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Self-Injurious Behavior in Adolescents

• WJCIA Annual Training Conference
• Stevens Point
• September 28, 2007

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• Kay F. Heimerl, MS LCSW
• Outagamie County DHHS
• heimerkf_at_co.outagamie.wi.us
• [phone]

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Self Injurious Behavior

• How will you know Im hurting
• If you cannot see my pain?
• To wear it on my body
• Tells what words cannot explain.
• - C. Blount

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Definition

• An injury to ones own body, done without
  suicidal intent or intent to attain sexual
  gratification.
• Self-inflicted harm is enough to cause tissue
  damage.
• Not part of spiritual ritual or for ornamental
  purposes.
• Done as a way to alter a perceived intolerable
  mood state.

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Demographics

• 3 million Americans
• 1 of the general population
• Males and Females
• Middle class and educated
• History of abuse and/or trauma
• Often starts in early teens, peaks from ages
  18-24, decreases in 30s and 40s

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Methods of SIB

• Cutting
• Burning
• Scratching
• Picking
• Interfering with wound healing
• Head banging
• Hitting self

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Methods of SIB cont

• Breaking bones
• Hair pulling
• Spooning
• Eating harmful objects lightbulbs, glass,
  plastic
• Ingesting chemicals
• Over/under eating

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Comorbid behaviors

• Reckless driving
• Unprotected sex
• Shoplifting
• Promiscuity
• Substance abuse
• Eating disordered behavior

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Wound Severity

• Extent of the damage
• Level of medical intervention required
• Location of the wound

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High Risk Groups

• Emotionally disturbed children
• History of trauma/abuse
• Borderline Personality Disorder
• Young males with psychosis
• Gender identity disorders
• Dissociative disorders

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High Risk Groups cont

• Substance abusers
• Teens whose parents are physically or emotionally
  unavailable to them
• Teens with untreated depression or anxiety

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Why do people self injure?

• .

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Because it works!!!All self-injury is designed
to feel good at that moment.
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Purpose of SIB

• Relief from psychological pain
• Release of tension
• Affect regulation cant feel, feel too much
• Communicate feelings anger, sadness, pain, etc.

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Purpose of SIB cont

• Way of being in control
• Defense mechanism
• Feel the need to be punished
• To be unattractive
• Endorphins of physical pain cover up the
  emotional pain
• Event marker

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Attention seeking???

• Not usually
• Sometimes done to induce rescuing behaviors in
  others
• Can provide an opportunity for self-care
  afterwards

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Attention Seeking???

• Actually it is often under-diagnosed and
  under-reported due to
• Shame, guilt, fear, pride
• Learned distrust of others
• Fear of legal consequences
• Mixed feelings about treatment/recovery

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SIB is often preceded by one or more of these
emotional factors

• Depression
• Stress
• Hopelessness
• Powerlessness
• Purposelessness
• Anxiety
• Fear

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Psychological characteristics of Self Injurers

• Invalidate self
• Hypersensitive to rejection
• Pervasive anger
• Tend to suppress anger
• Impulsive
• High levels of aggressive feelings
• Act on immediate mood

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Psychological characteristics cont . . .

• Feel powerless over how or whether they cope with
  life
• Not future-focused
• Depressed/suicidal/self-destructive
• Anxious
• Lack of coping skills
• Avoidant

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How should we react?

• Dont ignore it!
• Always take it seriously.
• Dont judge!
• Show concern.
• Stay calm and sincere.
• Dont overreact, rescue or hyper-nurture.

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How should we react?

• Remember that it is a cry for help.
• Find out what is going on beneath the behavior.
• Listen! Listen! Listen!
• Dont punish! Any interventions should be
  designed to protect, not to punish.
• Acknowledge the SIB as a survival strategy.

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How should we react?

• Assess the extent of the injury and intervene
  appropriately.
• Let them know that it is OK to talk about their
  SIB.
• State that you cannot talk to the person while
  they are injuring because you care about them and
  it hurts you to see that.

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How should we react?

• Do not use ultimatums i.e. stop or else!
• Set reasonable limits.

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Interventions/Referrals

• You must find something to replace the behavior.
  You cant just take it away.

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Interventions/Referrals

• Psychotherapy many methods and interventions
• Trauma work therapy, PTSD Workbook, EMDR
• Contracts agree to try alternate behaviors
  before SIB
• Alternate behaviors need to be harm reducing
  rubberband snapping, hands in ice, chewing
  cinnamon or hot peppers, etc.

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Interventions/Referrals

• Medication
• Develop Personal Validation
• Spirituality
• Meditation
• Yoga, Tai Chi
• Appropriate physical releases

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Interventions/Referrals

• Group therapy DBT, Abuse survivors
• Family therapy
• Change core beliefs and values
• Teach emotional literacy feeling lists,
  journaling
• Safety bag

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Safety Planning

• Assessment questions
• Do you need to hurt yourself? What has brought
  you to this point?
• Have you been at this point before? What did you
  do then to deal with it? How did you feel then?
• What have you done to ease this discomfort in the
  past? What else can you do that wont hurt you?

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Safety Planning

• Assessment questions cont
• How do you feel right now?
• How do you feel after hurting yourself? How will
  you feel tomorrow morning?
• Can you avoid this stressor, or deal with it
  better in the future?

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Safety Planning

• Contracts
• List alternate behaviors to use before SIB
• Names and numbers of contact persons
• When to call Crisis
• When to seek medical attention
• Discuss placement options ahead of time if
  possible i.e. hospital, crisis bed, secure
  detention, family member, etc.

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Safety Planning

• Decide who will be included in the contract
  parents, school personnel, mentor, physician,
  etc.
• Determine length of contract viability
• Be clear about mandatory reporting obligations
  and potential consequences
• Consult with Mental Health professional

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QUESTIONS???