Under the Surface

1. Under the Surface Understanding Self-Injury July 10, 2008 Carolyn O. Lee, MSW, LCSW

2. What is Self-Injury? • Deliberate destruction or alteration of body tissue that occurs in the absence of conscious suicidal intent (Yates, 2006) • Intentional, non-life threatening, self-effected bodily harm or disfigurement of a socially unacceptable nature, performed while in a state of distress (Pearrow, 2006) • Intentional harming of one’s own body without suicidal intent (Alderman, 2000)

3. Aztec Sacrifices Inca Empire Injury to the Body-As Old as Time

4. Sundancers/Ancient Lakota Sioux Indians (Schwatka, 1800s) Each of the young men presented himself to a medicine-man, who took between his thumb and forefinger a fold of the loose skin of the breast—and then ran a very narrow-bladed knife through the skin. This was tied to a long rope fastened to the top of the sun-pole. To liberate himself he must tear the skewers through the skin.

5. Firewalkers Medieval Christians Other cultures, groups Self-Injury Culturally Sanctioned for Centuries in Many Cultures

6. Categories of Self-Injury • Major • Stereotypic • Superficial/Moderate-most common a) compulsive b) episodic c) repetitive b) & c), impulsive (Favazza, 1986, 1996)

7. Multiple Episodes Common • 63% experience multiple episodes (Lukomski, 2007) • Findings in a study of urban & suburban teens (Ross and Heath, 2002) • 75% of habitual self-injurers use multiple methods (Dean, 2007)

8. Methods of Self-Injury • Most common is Cutting, • Followed by Self-burning, • Pin-sticking, • Scratching, • Self-hitting, • Interference with wound healing, • Bone breaking (Lukomski and Folmer, 2007) • Other methods

9. Terms for Self-Injury • Self-Injurious behavior (SIB) • Deliberate Self-harm, Self-harm • Self-inflicted violence • Cutting, Self-cutting • Self-mutilation • Self-wounding • Parasuicidal behavior • Repetitive Self-Mutilation Syndrome

10. Why Self-Injure? • “To stay alive; how I cope.” (Teen client report) • Regulation of mood, affect, consciousness • Relieves anxiety, depression • Discharges anger • Self-punishment • Tension relief • Induces pleasure • To feel alive, real • Sense of control • Reenactment of Abuse

11. Definition: Having no words for feelings Self-injurers have difficulty verbalizing emotions (Dean, 2007) Theorized due to early maternal depravation (Farber, 2002) Bleeding: body’s weeping Alexithymia

12. SIB: Commonly Expressed Emotions • BEFORE: • DURING: • AFTER:

13. Distinguishing Between SIB & Suicidal Behaviors Most SIB is not suicidal in nature, but actually intended to preserve & restore psychic functioning ( Favazza, 2000; Walsh & Rosen, 2005) *Suicidal behavior--clear intention to die *Primary objective in 85% of SIB is tension relief opposed to suicide (Canver, 2006)

14. Suicide vs. Self-Injury • Self-injurers more likely to attempt suicide if (1) bullied; (2) sexually abused; (3) recently lost a loved one (Dean, 2007)

15. Self-Injury Can Be Lethal • Even if not the intention • Approximately 10% die (Farber, 2002)

16. Tattooing & Piercing—SIB? Someone else performs in a social context Designed to beautify (Alderman, 1997)

17. Possible Risk Factors • Emotionally invalidating environments • Anger issues • Abuse (sexual, physical, verbal) • Major trauma • Perfectionism • Loss of a loved one • Bullying • Friends/family who self-injure • Troubled relationships

18. Biological Bases of SIBThe Serotonin Link • Low levels linked to aggression, particularly self-aggression (Herpertz, Sass, & Favazza, 1997) • SSRIs often prescribed • “The psychotherapist actually is a neurotransmitter” (Winchel, 1991)

19. Biological Bases of SIBEndogenous Opiate Hypothesis • Self-injurers have lower levels • SIB may restore levels (Oquendo & Mann, 2000) • Addiction Hypothesis (Favazza, 1998) • Pain Hypothesis • Opiate antagonists prescribed

20. Biological Bases of SIBCortisol & Norepinephrine • Cortisol--levels may decrease w/SIB • Norepinephrine--higher levels associated w/aggressiveness (McVey-Noble, 2006)

21. Prevalence of Self-Injury • 4% of general population; 21% of clinical population • Most of the 2 million Americans that self-injure started as teens (Sullivan, 2002) • Across studies,12-14% adolescents

22. US Undergraduate Study • 9.8% admitted intentional cutting or burning at least once • When definition of SIB was expanded, 32% (Vanderhoff & Lynn, 2000)

23. Demographics- SIB across the Lifespan • Often begins in early adolescence • Peaks between 18-24 yrs • Decreases in 30s & 40s • Rare in elderly (Pierce, 1987)

24. Gender Differences-Conflicting Reports • Ross & Heath (2002), 64% of teens were female • Similar rates of SIB among males & females (Gratz, 2001; Brickman, 2004; Martin et al, 1995) • Typical self-injurer described (Canver, 2006) • Methods preferred, by gender • Places on the body preferred, by gender

25. Contagion • Copycat Cutting • Biological predisposition-SIB sticks if hardwired • Group disinhibition impacts contagion episodes (Farber, 2002) • “Epidemics” in treatment settings (Dean, 2007)

26. Media Influences • Celebrities & SIB • Prevalence in media • Effects on teens

27. Mental Illness & SIB At risk of SIB if diagnosed with: • Substance Abuse • Eating Disorders • Impulse Disorders • Depression • Phobias • Conduct Disorders • Borderline Personality Disorder

28. SIB, Drug & Alcohol Abuse • 58% of males & 37% of females had at least 1 drink 6 hours preceding SIB (Dean, 2007) • Hallucinogens rarely used • Amphetamines more popular

29. SIB & Multi-Impulsive Disorder • Most repetitive self-injurers engage in other impulsive behaviors • Studies show correlation b/t impulsivity & SIB (Farber, 2002; Dean, 2007)

30. SIB & Eating Disorders (ED) 50-61% of self-injurers have, or at one time had, an ED (Dean, 2007) Derealization & depersonalization, before & after (Farber, 1995, 2002) Characteristics common

31. Treatment of SIB • Combination of Psychotherapy, Medication, & School Support • Therapy takes several years • Treatment team recommended • Brief inpatient, if necessary

32. Research on Treatments • Limited research on teens, treatment, & SIB • Txs found to be unsuccessful: • Physical restraint • No cutting contracts • Hypnosis • Group psychotherapy • Family therapy • ECT • Faith healing • DBT individual skills training is effective

33. What to do for Urges of SIB • Collaborate in making a coping skills list • Discuss self-nurturing strategies • Help identify triggers • Help identify warning signs of escalation • Help her talk about her internal state • Be empathic

34. What Not to do for Urges of SIB • Encourage displays or lurid descriptions • Hyper-nurture • Take away sharp objects– disempowering • Prescribe behaviors that mimic SIB • Encourage cathartic methods (ex punching pillows) (Dean, 2007)

35. Treatment Considerations • Therapy is to “give sorrow words” (Holmes) • “to be known & remembered by another” (Farber, 2002) • Welcome the hated body (Orbach, 2003) • Engage the body’s wisdom (What would your wrists say if they could talk? Words for actions) • Understand function (How does SIB help you?) • Must experience her own giving up of SIB (Farber, 2002; Byck, 2007)

36. Psychotherapy When the patient has nobody to whom he can turn for soothing, it feels as if he has no body. So to attack his own body means that there is a body there, that there is somebody for him. To be somebody without having to attack the body means using words with somebody who can listen, so that meaning can be created. It is a way of making real a life that had seemed unreal and was lived in an unreal or dissociated way. The patient becomes real in the relationship with the therapist in the same way that a toy becomes real to a child. Sharon Klayman Farber, Ph.D

37. Becoming Real

38. Video Clip References www.youtube.com/watch?v=mkiZZHmWaf8 (In My Room- Cutting Story; mettaproductions) www.youtube.com/watch?v=U5AawiavtR8 (Scenes from the movie Thirteen) www.youtube.com/watch?v=5UZzHaOG2ul (Britney Spears, Every Time video) www.youtube.com/watch?v=cwlkGKJrs2E (ED & SIB in movies, TV, music videos)

39. Book References Farber, S. (2002). When the Body Is the Target: Self-Harm, Pain, & Traumatic Attachments. Northvale: Jason Aronson Inc. Favazza, A. R. (1996). Bodies Under Siege: Self Mutilation & Body Modification in Culture and Psychiatry. 2nd Edition. Baltimore: Johns Hopkins University Press. Hassrick, R. (1964). The Sioux. Norman, Oklahoma: University of Oklahoma Press. Levenkron, S. (1998). Cutting: Understanding & Overcoming Self-Mutilation. New York: W.W. Norton & Co.

40. More Book References McCormick, P. (2000). Cut. New York: Push/Scholastics, Inc. McVey-Noble, M., Khemlani-Patel, S. & Neziroglu, F. (2006). When Your Child Is Cutting- A Parent’s Guide to Helping Children Overcome Self-Injury. Oakland: New Harbinger. Miller, D. (1994). Women Who Hurt Themselves: A Book of Hope & Understanding. New York: Basic Books.

41. Clip Art References Self-Injury: A Struggle (section that has self-injurers display their artwork and poetry) Google Images

42. Internet References American Academy of Child & Adolescent Psychiatry- Facts for Families #73 American Self-Harm Information Clearinghouse LifeSIGNS Mental-Health-Matters.com National Mental Health Association Fact Sheet Psyke: Self-Injury Information and Support RecoverYourLife.com Safe Alternatives

43. More Internet References Self-Injury: A Struggle Sirius Project: Self-Help for Self-Harm Self-Help for Self-Injury The National Self Harm Network www.childline.org.uk www.selfharmUK.org www.selfharm.org.uk www.youngminds.org.uk

44. Conference References Creative Destruction: Art-Based Applications with Eating Disordered Clients Who Self-Injure. Presented by: Michelle Dean, MA, ATR-BC, LPC, CGP. October, 2007 in Cary, NC. When The Body Speaks: Psychotherapy with People who Self-Injure. Presented by: Judy Byck, MSW, LCSW. November, 2007 in Chapel Hill, NC.