Cutting it Fine: Self-Injury in C ntext

1. Cutting it Fine:Self-Injury in C ntext Professor Graham Martin

2. John Oh! Do it again Doc!

3. The Inner Pain Jenni (14) electively mute after she was raped. She repeatedly harmed herself in small ways but for 4 months could not verbalise either her feelings or what had occurred.

4. The Size of the Problem 750 per 100,000 Conterio and Favazza, 1986 1800 per 100,000 young women between 13-35 Suyemoto & McDonald 1995 444 teens - 13.9% had engaged in SI Ross and Heath 2002

5. In Children Office of National Statistics study of 10,000 parental reports of mental health By age 15 years 2-3% have self-injured Between 9.4% in anxious and 18.8% in depressed young people

6. EDED Study(1st year High School - aged 13) Deliberate Self-Injury - 273 (14.3%)

7. EDED study - logistic regression Classic correlates of depression and sexual abuse - not significant Surprise finding of physical abuse and anxiety as major predictors Only suicide attempt predicted the multiple episodes

8. The Picture 97% female Peaks in 20s to 30s Hurting self since teens Middle class or above Intelligent Well educated History of physical/sexual abuse Will admit to up to 50 acts 57% had also overdosed Hospitalised average of 240 days Conterio and Favazza, 1986

9. Self Injury Motivation Scale To show others how hurt I feel To distract myself from emotional pain To punish myself for being bad To decrease an empty feeling To produce a feeling of numbness To keep bad memories away To reduce a feeling of being utterly alone

10. Stimulus to Self Injure Threat of separation or abandonment Rejection or disappointment Feeling of isolation Another crisis

11. Type of injury Cutting 72% Burning 35% Self Hitting 30% Interference with wound healing 22% Hair pulling 10% Bone breaking 8% Multiple 78% Conterio and Favazza, 1986

12. Endogenous opioid system Suppression of pain Approx 60% feel no pain (Bohus et al., 2000; Russ et al., 1993) Abuse/neglect/trauma might alter EOS & reduce sensitivity to pain (Kirmayer et al., 1987; van der Kolk, 1989; Dubo et al., 1997; van der Kolk et al., 1991) Decrease in pain sensitivity following early traumatic experiences has been reported in both animal and human studies (Russ et al., 1993)

13. Pain perception Reduced pain perception even when relaxed (increased threshold for pain perception) During distress, pain perception is further reduced

14. Part TwoWhen should you worry?

15. Belly Ring Has gained acceptance in our society

16. Eyebrow Body Art Also accepted

17. Tongue Studs Perhaps less accepted or acceptable

18. Ear Piercing One or two?

19. Ear piercing Or more?

20. Facial Piercing Over the top?

21. Lips and Noses A little harder to take perhaps

22. Kelly

23. Artificial Scar Now we are getting problematic

24. Stomach Cutting More Serious Typesof Self Injury

25. �Biohazard� and �Skull� More Serious Typesof Self Injury

26. STEPS TO EFFECTIVE PRACTICE WITH SELF-INJURY IN YOUNG PEOPLE

27. The Holding Environment -�Jane�

28. Advice for Teachers Often first to discover SI Let teen know available to listen Encourage them to talk to parents Encourage teen to discuss thoughts about SI Ask about suicidal thoughts and plans Seek immediate help if needed Encourage professional evaluation

29. If�� Then If you are anxious about helping with the crisis, managing the process, or doing the therapy, then trust your own feelings Seek alternative care for the young person OR Alternatively seek regular supervision to enable you to cope with confidence

30. If�� Then If the self injury needs medical attention then seek appropriate help. Ensure the young person is not treated badly, roughly or with disdain by medical or other staff. Explain, if you have to, that at this time this is the only way they can seek help

31. If�� Then If a professional complains that the young person is �attention seeking�, then gently and respectfully explain that is exactly what they need - attention. It is just that, at this time, we have not been able to help them share their inner pain

32. CRISIS INTERVENTION Listening and Responding Define the Problem Ensure Safety (Client, Family & your own) Provide Support Acting and Involvement Examine Alternatives Make Plans Gain Commitment

33. CRISIS INTERVENTION Never be sworn to secrecy Up front, make it clear that what is said may be confidential, but you have the right to make your opinion public - particularly if you think the young person�s life (or someone else�s) is in danger

34. CRISIS INTERVENTION Do not focus, at this time, on the self injury more than you have to in ensuring safety Focus on developing a supportive relationship, a clear plan for ongoing care, and/or a therapeutic alliance A relationship A set of clear tasks Toward a clear goal (short and/or long-term)

35. Distraction TechniquesAmerican Academy of Child & Adolescent Psychiatry Counting to 10 Waiting for 15 mins �Thought stopping� Breathing Exercises Journaling Drawing Thinking about Positive Images Using Ice Using Rubber Bands

36. If�� Then If you feel the young person is (for instance) depressed then try to get some simple measure of this Trust the young person�s responses Use a Visual Analogue Scale (0-10)

37. If�� Then If the scale score is 7 or over out of 10 then try to find out whether �life is worth living� If the answer is no, then check for any reasons the young person may have for living (future, family, friends) Be gently persistent

38. If�� Then If the outlook is bleak (and it may well be), then check for suicidal thoughts (score 1) If the thoughts are persistent, intrusive and frequent (eg daily), then check for specific plans (how to get means, what pills and how to get them) (score 3)

39. If�� Then If there are plans, then check if the self injury was part of the plan (Do not assume) Check whether the young person wishes to die, realising that this is a �long term solution to what may be short term problems�

40. If�� Then You already know of the self harm (score 4) If the young person has threatened someone they will die then score an additional 2 If the score from thoughts, threats, plans, attempts or the self harm is only 4 (the self harm), you should be able to manage��

41. If�� Then If the young person actively seeks to die, then ask about previous attempts (score 5) Check for Intent (Did they seek to die at that time?) (score an additional 1) Check for Lethality (score an additional 1)

42. If�� Then If the total score is 5 - 7, then you may need to seek help with the management If the score is 8 or above then the young person may be not only self-harming, but also at serious risk of suicide. You may have to hospitalise. Never take the decision alone

43. If�� Then If at all possible, involve the family or some other person or agency in the community Never carry the load alone - its not clever!

44. Therapy Brief Focused Therapies CBT Narrative Solution Focused Family Therapy Group based semi-manualised IPT Manage with admissions under the young person�s control

45. Impetus for the MOSH Study Original Study in the UK Wood A, Trainor G, Rothwell J, Moore A and Harrington R, �Randomised trial of group therapy for repeated deliberate self harm in adolescents� J. Am Acad Child Adolesc Psychiat 40, 1246-1253, 2001)

46. UK Results: Main Hypotheses(Wood et al., 2001) Strong effect on repetition Group Therapy + TAU (2/32 - ie 6%) compared with Routine Care group (10/31 - ie 32%) OR = 6.3 (95% CI = 1.4 - 28.7) Fewer episodes of self-harm (0.6 vs 1.8 mean episodes in follow-up) Longer time to first repeat (11.9 weeks vs 7.0 weeks) (4.9 weeks difference : p < 0.05)

47. Depressive Symptoms and Ideation (Wood et al., 2001) Change at 28 weeks Mood & Feelings Questionnaire (MFQ 0-68) Group Treatment 18.8 Routine Care 15.3 Suicidal Ideation Questionnaire (SIQ 0-180) Group Treatment 47.3 Routine Care 39.7 Significant improvement from baseline to 28 weeks, but no significant impact of Group Treatment. Numbers (63) too small to achieve statistical significance

48. Number of Therapy Sessions:Impact on Mean self harm episodes (Wood et al., 2001) Mean self harm episodes No. of Sessions Group + TAU 0-3 1.2 1.1 4-9 0.5 0.9 >10 0.3 4.1 Confounding factors were Baseline self harm, HONOSCA score, and small numbers in study (63)

49. Current Programs SIMS Study Adolescent Ward, RBH RCT Group Therapy in 12-17 year olds Development of Training Materials SI Internet Site evaluation study National Epidemiological Study Collaborations with Dr. Penny Hasking Another 15 or so ideas in development

50. CODA

51. Resources Selekman, MD (2002). Living on the razor�s edge: Solution-oriented brief family therapy with self-harming adolescents. New York, Norton. www.focusas.com/SelfInjury.html www.siari.co.uk/ www.angelfire.com/md2/simianline/selfinjury.html