Understanding and Responding to Students who Self-Mutilate

1. Understanding and Responding to Students who Self-Mutilate RICHARD LIEBERMAN Los Angeles Unified School District Suicide Prevention Unit (818) 705-7326 rlieberm@lmu.edu

2. Challenges to School Site Crisis Teams • Overwhelming numbers of referrals • Low risk suicide assessment • Behaviors appear contagious

3. Common Myths of SM • Myth #1.Self-mutilators use this behavior to manipulate other people. • Myth #2.Self-mutilation is synonymous with suicide. • Myth #3.Self-mutilators are dangerous and will probably harm others. • Myth #4.Self-mutilators just want attention. • ___________________________________________ • Adapted from: Froeschle & Moyer (2004). Just cut it out: Legal and ethical challenges in counseling students who self-mutilate. Professional School Counseling, April, 2004.

4. Continuum of Self-destructive Behavior • SUICIDE • HOMICIDE Stressors Warning signs Thoughts Behaviors

5. Definitions • Inclusion of other Self-Injurious Behaviors (SIB) • Distinguish from ritual tattooing, branding and piercing • Not related to cognitive impairment

6. Definitions (2) “The definition of self-mutilation is that it is a direct, socially unacceptable, repetitive behavior that causes minor to moderate physical injury.” Suyemoto&Kountz (2000) Self-Mutilation The Prevention Researcher Nov., Vol. 7 No 4

7. Classifications Of Pathological Self-mutilation • Major Self-mutilation • Stereotypic Self-mutilation • Moderate/Superficial Self-mutilation

8. CLASSIFICATIONS:Major Self-mutilation • Infrequent act that occurs suddenly, with a great deal of tissue damage and bleeding. • Most commonly associated with psychosis and acute intoxication. • Religious or sexual themes may be present.

9. CLASSIFICATIONS:Stereotypic Self-mutilation “Driven by a biological imperative to harm themselves shamelessly and without guile” Favazza • Most common form: head banging • Most common population: Institutionalized/psychotic • Self-injurious behaviors (SIB)

10. CLASSIFICATIONS:Stereotypic Self-mutilation • Autism (head banging, lip/wrist biting) • Retts disorder (hand washing) • Tourettes (multiple simple and complex tics, variety SIB) • Use of medication is common though behavior therapy is primary modality.

11. CLASSIFICATIONS:Moderate/Superficial Self-mutilation • Most common: skin cutting, burning • Compulsive: Hair pulling, scratching. • Episodic: Rapid respite from distressing thoughts/emotions/tension; regain sense of self control. • Repetitive: Addiction to self harm.

12. Diagnosis Repetitive Self-mutilation Syndrome (RSM) RSM is recurrent failure to resist impulses to harm one’s body physically without conscious suicidal intent. Bodies Under Siege Self-mutilation and Body, Modification in Culture and Psychiatry Armando R. Favazza, M.D. Hopkins University Press Baltimore/London

13. Diagnosis (2) • RSM can be associated with many disorders • Borderline personality disorder • Depression: mood & anxiety disorders • Post traumatic stress disorder

14. Diagnosis (3) • Impulse disorders: Episodic/gratifying • Alcohol & substance abuse • Suicide attempts • Eating disorders • Repetitive self-mutilation

15. RSM: Prevalence & Onset • Onset: late childhood-early adolescence • Rates higher in adolescence: approximately 1400 per 100,000…roughly 13% • Rates higher in females • Rates higher in psychiatric pop. • Behaviors may become chronic and persist for 5-10 yrs. or longer if left untreated.

16. RSM:Predisposing Factors • Onset linked to “stressful” situations • Physical/sexual abuse in childhood • Family violence • Early history of hospitalization/surgery • Parental alcoholism/depression • Perfectionist tendencies/dissatisfaction with body • Inability to tolerate and express emotions

17. RSM:Precipitating events • Chaotic families characterized by divorce, neglect or deprivation of care • Loss of a parent • Parental loss = emotional distancing and inconsistent parental warmth • Physical/sexual abuse • Having a sibling who engages in SM • Witnessing family violence

18. RSM:Precipitating events (2) • Recent loss or death • Peer conflicts • Intimacy problems • Break up of romance • Rejection of human interconnection • Fear of abandonment

19. Want to feel concrete pain when psychological pain is overwhelming Reduces numbness Keeps trauma from intruding Gets attention of others Discharges my anger and despair Gain a sense of control A way to punish myself Functions of SM:What Do Kids Report?

20. Functions of SM • Meets a multitude of needs • Relief from overwhelming feelings • Communication • Stop inducing or preventing dissociation Alderman, T. (1997) The Scarred Soul: Understanding and Ending Self-Inflicted Violence (New Harbinger Press, Oakland, CA.)

21. Functions of SM • Self-punishment: scars/blood concrete reminders • Physical expression of pain • Re-enacting previous abuse

22. Functions of SMBottom Lines • Euphoric feelings • Establishing control “Self-mutilation is an active, direct, concrete representation of intense anguish.”

23. Phenomenology • “Although self-mutilators sometimes report feeling guilty or disgusted after an incident, most adolescents report feeling relief, release, calm or satisfaction…ending the anger, tension or dissociation.” • Suyemoto K.(1998) The functions of self-mutilation. Clinical Psychology Review, 18(5), 531-554

24. Phenomenology • Isolation • Engages in SM in isolation • Masks behaviors and injury with clothes • Having friends that are not friends with each other places at greater risk • Alpha teens • Borderline personality: female • Anti-social personality: male

25. Phenomenology • Contagion • Teens at height of imitative behavior. “rite” of togetherness • Exposure to SM and parasuicidal behavior raises risk in youth • May spread among peer groups, grade levels, clubs • Monitoring personal reactions • Caregiver’s emotional responses to SM • Caregiver responses to student • Recognize limitations

26. Prevention • Protective factors • Connectedness; access to mental health; spiritual life; stable families • Crisis preparation • Crisis teams; referral procedures; updating local resources (DCFS) • Training • Psycho-education • Primary prevention programs • Depressions screening; alcohol and substance abuse; bullying

27. Treatments • Biological • Psychological and Social • Cognitive/Behavioral Therapy “There is no single, correct therapeutic approach. Prevention is key.” Favazza

28. Treatments:Biological • Serotonin (SSRIs) • Prozac, Paxil, Zoloft • Preferred treatment for depression and anxiety disorders. • Primarily affect on impulsivity/compulsivity • FDA advisory

29. Treatments:Psychological and Social • Making and maintaining a relationship • Breaking the habit • Maintaining change Tantam & Whitaker (1992)

30. Treatments:Psychological and Social • Analyze precipitating events • Identify thoughts and emotions • Where/how wounds • Goal: Reduce tensions • Gain control over cutting Hawton (1990)

31. Treatments:Cognitive/Behavioral Therapy • Connection between thoughts and behaviors • Facilitated by directing attention away from environment and towards thoughts • Replace negative perceptions with focus on positive qualities. • TADS

32. Treatments:Dialectical behavioral therapy • Pioneered by Marsha Linehan in work with Borderline personality disorder • Combination of individual, group and skills training • Hierarchical structure of treatment goals • Success in reducing parasuicidal, SM behaviors as well as reducing behaviors that interfere with therapy

33. Responding to Students who Self-MutilateIntervention • Advocate and educate: Create a climate of trust with the student • Legal and ethical issues • Identify and refer • Suicide assessment • Build and tighten “Circle of Care”

34. Responding to Students who Self-MutilateIntervention: Suicide assessment ASSESSMENT: LOW RISK (Ideation) • Question:Have you ever thought about suicide (harming yourself)? • Observed behaviors: current or recent thoughts or depression; direct or indirect threats, sudden changes in personality, friends, behaviors; evidence of self harm through written or art work • Actions:Reassure and supervise student; warn parent; assist in connecting with school and community resources; suicide-proof environments; mobilize a support system; utilize no-harm agreements

35. Responding to Students who Self-MutilateIntervention: Suicide assessment ASSESSMENT: MODERATE RISK • Previous behaviors • Question:Have you ever tried to kill (hurt yourself) before? • Observed behaviors: previous attempts, hospitalizations, trauma (losses, victimization); recent medications for mood disorders; running into traffic, jumping from high places; RSM

36. Responding to Students who Self-MutilateIntervention: Suicide assessment ASSESSMENT: HIGH RISK • Current plan and access to method • Question:Do you have a plan to kill (harm) yourself today? • Observed behaviors: current plan; finalizing arrangements by giving away prized possessions or written/e-mailed good bye notes; refusal to sign no-harm agreement

37. Responding to Students who Self-MutilateIntervention: Suicide assessment ASSESSMENT: MODERATE/HIGH RISK Actions: • Supervise student (including rest rooms) • Hand off ONLY : • Parent • Law enforcement • Psychiatric mobile responder • Prepare re-entry plan.

38. Responding to Students who Self-MutilateIntervention • Warning parents • Obtain relevant mental health history including insurance information; traumatic losses; victimization; signed release of information • Utilize no harm agreements • Connectedness with adults • Help–seeking behaviors • Communication skills • Grief resolution • Provide hotlines/websites • Hotlines: • (800) SUICIDE • (800) DONTCUT • Internet • selfinjury.com • selfharm.org.uk • selfabuse.com • Google

39. Responding to Students who Self-MutilateIntervention:Tension Release • Get active: Exercise • Stress management techniques • Yoga, breathing, meditation, visualization, martial arts, Tai Chi • Alternative therapies include art and play therapy

40. Responding to Students who Self-MutilateIntervention:Communication skills • Help seeking behaviors • Journals/drawing to aid ventilation of emotions • Play: with younger • Advocacy: reaching out to others • Cognitive behavioral approaches

41. Responding to Students who Self-MutilateIntervention: Substitute behaviors • Rubber bands • Holding books out at arms length • Standing on tip toes • Substitute ice or magic marker for sharp implement • Parent permission!

42. Responding to Students who Self-MutilateReferences: • Lieberman, R. & Poland, S. (in press). Understanding and responding to students who self-mutilate. In G. Bear & K. Minke, Children’s needs III. Bethesda, MD: National Association of School Psychologists. • Lieberman, R. (2004). Understanding and responding to students who self-mutilate. National Association of Secondary School Principals: Principal Leadership 4(7) 10-13. • Poland, S. & Lieberman, R.A. (2002). Suicide intervention. In Thomas, A. & Grimes, J., Best practices in school psychology IV. Bethesda, MD: National Association of School Psychologists. • nasponline.org