A Collaborative Approach to Understanding & Treating Self-Harming Behaviours

1. A Collaborative Approach to Understanding & Treating Self-Harming Behaviours Theresa Faubert, BA, CYW, CYC (Cert) theresa.faubert@rogers.com Patty Hayes, MSW, RSW, MDiv pattyhayespcc@gmail.com

2. Goals for the Workshop • Begin to define and understand what constitutes “self-harming behaviours.” • Examine these behaviours from a bio-psycho-social perspective. • Look at some possible intervention strategies, including a harm reduction approach.

3. What is Self-Harm? • The term self harm is also referred to as: deliberate self harm (DSH), intentional self harm, self mutilating behaviour (SMB), self wounding, self inflicted violence (SIV), non-suicidal self injury (NSSI) and parasuicide as well as (failed) suicide attempts. • The motivation of the act is what differentiates the diagnosis and treatment.

4. What is Self-Harm (cont.) • Self harm is distinguished by three identified meanings “Coping, Control and Validation.” • Coping: is described as “tension release, alleviating unpleasant emotions and inducing a shift in affective state” Control over a chaotic environment; and Validation of self by concretizing emotional or psychological pain.

5. Self-Harm v. Suicide: A Continuum • Motivation distinguishes self-harm from suicidal behaviour. • There seems to be common consensus that methods involving low lethality are more apt to constitute self-harm. • Self-harming behaviours are on a continuum. • Thrill NSSI Suicidal Suicidal Seeking Ideation

6. Prevalence • As a result of the shroud of secrecy inherent in acts of self harm, incidences are typically under-reported. • 4% of general population; 21% of “clinical populations without mental retardation or developmental disability.” (Kress, 2003). • Average age of onset is 12-15 years old. • Self-harming behaviours in younger children may go unnoticed (picking at scabs, falling down to get hurt).

7. Prevalence Cont. • Research indicates that seniors are more likely to use poisoning, more more likely to be hospitalized in response to their self-harming behaviours, and have episodes of self-harming which are less likely to result in completed suicide. • Numerous studies have shown that self-harming behaviours can be found across cultures, ethnicities and language groups.

8. Taking a Bio-Psycho-Social Approach to Understanding Self-Harm • No one dimension can account for why someone might engage in self-harm behaviours. • Each person engages in self-harm for a different set of reasons. • Our best framework for understanding self-harming behaviours uses an ecological approach.

9. An Ecological Approach Using an ecological approach to understanding self-harm allows us to identify key areas and examine how the interrelation between the key domains affect a youth to engage in self-harming behavior.

10. Biology - The brain & body at work • Psychiatric/Medical Issues • Depression • Bipolar • Schizophrenia • Anxiety • Eating Disorders • Dementia (in older adults) • Endorphins – a biochemical high

11. Biology – That’s Using Your Brain! • Teen Brain Development – frontal lobe is not fully developed which effects, among other things, impulse control and executive brain functioning. • Research is also showing that prolonged exposure to trauma and neglect can have an effect on brain functioning and development.

12. Social - Gender Differences • Female to male ratios range from 2:1 to 20:1 depending on the study. • Recently, however, research has indicated that the number males engaging in self harm are on the rise. • Boys’ and men’s self-harm behaviours tend to be labeled as “risk taking.” • Males tend to complete more suicides than females. • Male and Female social constructs may have an impact on the view of self-harm behaviours as research has historically been conducted with females. Clinically we are seeing more males presenting with cutting behaviour.

13. Social/Environmental - Contagion Factor • Studies are conflicting about whether or not self-harming behaviours are subject to the contagion effect. • There are some social groups in which engaging in self-harm is an identifying factor (emo v. scene kids).

14. Validating Environment • One potential risk factor is to what degree a person’s environment is validating or leads a person to doubt her/his experiences. • Factors which may create a invalidating environment include: • Abuse • Poor “fit” between the individual and others who are close (eg. Poor parent-child fit)

15. Psychological – What Function Does the Behaviour(s) Serve? • Cope with tension and anxiety. • Express repressed emotions, especially anger. • Re-create the trauma. • To have a sense of control • Return from Dissociative States. • Self-Hatred/Punishment.

16. Functions (cont.) • Self-medication • Break through numbness. • Get a rush/high from endorphins. • To “gain attention”/call attention to something deeper.

17. Assessment • Observe for clues if the person hasn’t disclosed yet (eg. Long sleeves on a hot day). • For those who have disclosed: • Ask where they cut (you’ll have to gauge whether/when to inspect). • Ask what they use. • Ask how often and when the last time was.

18. Assessment Cont. • Ask questions to get a first sense of the underlying psychological process: • Do you remember cutting yourself? • What do you usually feel just before you cut? (numb, angry, lonely, anxious, etc.) • What do you feel afterwards? (relief, shame, a “high”, numb) • Do you plan ahead or is it spontaneous?

19. Interventions • What interventions are used depend on whether or not the person is ready to stop the behaviours.

20. Building a Multidisciplinary Team • Medical – to provide a safe & compassionate space to address medical issues which may arise, including those not related to NSSI. • Psychiatry – to assess for and manage potential underlying psychiatric issues. • Social Work/Counselling – to provide individual & family support; to help case manage. • Other Collaterals – eg. School; spiritual religious supports; social supports, etc.

21. Harm reduction • If the person is not prepared to stop, use harm reduction strategies: • Provides for some health and safety measures. • Allows the person to start to feel some sense of control over her/his body and actions. • Using Motivational Interviewing at this stage may be helpful in building a person’s motivation and confidence to change.

22. Harm Reduction Strategies • Assisting the person to get appropriate medical supplies. • Teaching proper wound care. • Teaching proper sterilizing & disposal techniques for the “implements” used for self-harming. • Safety planning around medical and mental health emergencies. • Coaching the family to let the person tend to her/his own wounds.

23. Motivational Interviewing • Use various empathy and advanced empathy responses to: • Demonstrate you are non-judgemental. • To help both you and the person begin to explore some of the factors which may be driving the behaviours. • To “roll” with resistance. • To help develop discrepancy between the person’s preferred life goals and her/his current behaviours.

24. Motivational Interviewing • Use Decisional Balance Sheets to: • Gain a better understanding of what factors may be keeping the person “stuck.” • To increase motivation. • To increase confidence. • To begin to develop strategies/plans specific to the person.

25. Stop the Ride, I Wanna Get Off! (When the Person is Ready to Stop) • Manage any on-going psychiatric issues. • Support the person in seeking out appropriate kinds of therapy. • Cognitive Behavioural Therapy (CBT) • Dialectical Behavioural Therapy (DBT) • Recovery is a process, not a product. Expect there will be slips and that progress will not always be even.

26. CBT - Thoughts, Feelings & Behaviours • Thought Records • What happened? • What were the feelings and at what intensity? • What were the thoughts? • What were the behaviours? • Behavioural interventions • Activity scheduling • Substituting other behaviours • Relaxation training • Deep breathing • Progressive muscle relaxation • Visualization

27. DBT • Usually involves group and individual work. • Elements include: • Emotional Regulation • Problem Solving Skill Development • Distress Tolerance Skills • Mindfulness

28. There is Hope for Recovery!! • “I had always sensed that [Self Inflicted Violence], for me, was related to survival. I did not understand all the dynamics bringing on SIV, but I had experienced it as an alternative to suicide or psychic implosion… Without survival, there would have been no possibility for healing.” - Ruta Mazelis (emphasis ours)