Understanding and Responding to Students who Self-Mutilate

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

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

3. MYTHS • The cutter is attempting suicide. • All cutters have been physically or sexually abused.

4. CONTINUUM OF SELF-DESTRUCTIVE BEHAVIOR • WARNING • STRESSORS SIGNS • SUICIDE • HOMICIDE

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 • Impulse disorders: Episodic/gratifying • Alcohol & substance abuse • Suicide attempts • Eating disorders • Repetitive self-mutilation • Post traumatic stress disorder

14. Repetitive Self-mutilation SyndromePREVALENCE & ONSET • Onset: late childhood-early adolescence • Rates higher in adolescence: approximately 1400 per 100,000 • Rates higher in females • Rates higher in psychiatric pop. • Behaviors may become chronic and persist for 5-10 yrs. or longer if left untreated.

15. Repetitive Self-mutilation SyndromePREDISPOSING FACTORS • Onset linked to “stressful” situations • Physical/sexual abuse in childhood • Early history of hospitalization/surgery • Parental alcoholism/depression • Perfectionist tendencies/dissatisfaction with body • Inability to tolerate and express emotions

16. WHY DO PEOPLE ENGAGE IN SELF-INFLICTED VIOLENCE? • 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.)

17. WHY DO PEOPLE ENGAGE IN SELF-INFLICTED VIOLENCE? • Self-punishment: scars/blood concrete reminders • Physical expression of pain • Re-enacting previous abuse

18. WHY DO PEOPLE ENGAGE IN SELF-INFLICTED VIOLENCE?Bottom Lines • Euphoric feelings • Establishing control “Self-mutilation is an active, direct, concrete representation of intense anguish.”

19. 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

20. PHENOMENOLOGY (2) • Precipitating event: usually the perception of an interpersonal loss or abandonment • Poor coping skills • Reacting to overwhelming emotions by dissociating • Isolation

21. FAMILY AND DEVELOPMENTAL FACTORS • Families characterized by divorce, neglect or deprivation of parental care • Parental loss = emotional distancing and inconsistent parental warmth • Often a history of childhood physical/sexual abuse

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

23. TREATMENTS:Biological • Serotonin (SSRIs) • Preferred treatment for depression and anxiety disorders. • Primarily affect on impulsivity/compulsivity

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

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

26. 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.

27. SCHOOL INTERVENTIONS:General strategies for Educators • Consider outside referral • Strategies related to increasing abilities to verbalize and express emotions • Teach coping skills: loss • Connectedness with caring adults

28. SCHOOL INTERVENTIONS:General strategies for Educators • Talk about self-inflicted violence • Be available and supportive (keep your negative reactions to yourself!) • Set reasonable behavioral limits • Do not discourage self-injury

29. SCHOOL INTERVENTIONS:General strategies for Educators • Substitute behaviors • Stress management techniques • Alternative therapies include art therapy and EMDR • Recognize the severity

30. SCHOOL INTERVENTIONS:General strategies for EducatorsSubstitute behaviors • Help seeking behaviors • Journals/drawing • Get active: exercise • Advocacy: reaching out to others • Cognitive-behavioral approaches

31. SCHOOL INTERVENTIONS:General strategies for EducatorsSubstitute behaviors • Rubber bands • Holding books out at arms length • Standing on tip toes • Substitute ice or magic marker for sharp implement

32. SCHOOL INTERVENTIONS:General strategies to limit contagion • Divide • Assess for suicide risk • Get parents involved and supported • Utilize school/district/community extracurricular resources • Do not have assemblies, presentations or show videos

33. WARNING SIGNS OF YOUTH SUICIDE • Suicide notes • Threats • Plan/method/access • Depression (helplessness/hopelessness) • Masked depression (risk taking behaviors, gun play, alcohol/substance abuse) • Giving away prized possessions

34. WARNING SIGNS OF YOUTH SUICIDE • Efforts to hurt self • Running into traffic • Jumping from heights • Scratching/cutting/marking the body • Death & suicidal themes • Sudden changes in personality, friends, behaviors

35. SCHOOL SITE CRISIS TEAM • Members: • Designated reporter • Administrator • Support personnel • Assess and Advise • Collaborate with law enforcement and local mental health resources

36. SUICIDE INTERVENTIONProcedures • Assessment of risk • Duty to warn • Duty to refer • Caveats: • Collaboration • Documentation

37. RISK ASSESSMENT • LOW: Ideation? • MODERATE: Previous suicidal behaviors? • HIGH: Current plan method/access?

38. SUICIDE INTERVENTION:Risk Assessment • LOW: Ideation? “Have you ever thought about suicide (harming yourself)?” • Current thoughts • Past thoughts (<6 months) • Non-verbal warning signs (writing/drawing)

39. SUICIDE INTERVENTION:Risk Assessment • MODERATE: Previous suicidal behaviors? “Have you ever tried it before?” • Previous attempts/gestures/RARD • Previous hospitalizations • Previous trauma (abuse, victimization) • Medications

40. SUICIDE INTERVENTION:Risk Assessment • HIGH RISK: Current plan? “Do you have a plan to kill yourself now? How would you do it?” • Method? Assess access • Firearms mentioned? • Refusal to sign no-harm agreement

41. SUICIDE INTERVENTION:Risk Assessment:Exacerbating factors • Precipitating events • High stressors (family, school, loss) • Poor access to resources

42. SUICIDE INTERVENTION:Intervention strategies • LOW RISK: • Reassure and supervise student • Warn parent • Assist in connecting with school and community resources • Suicide-proof environments • Mobilize a support system • No-Harm agreements • Transportation issues

43. SUICIDE INTERVENTION:Intervention strategies • No-Harm agreements emphasize: • Connectedness with adults • Help–seeking behaviors • Communication skills • Grief resolution • Linkages with community and district resources

44. SUICIDE INTERVENTION:Intervention strategies • MODERATE /HIGH RISK: • Supervise (restrooms, bus) • Release to: • Parent (may not be appropriate if child is high risk) • Law enforcement • Psychiatric mobile responder • Release adult to: 3rd party; IUSD Employee? Call District Office.

45. SUICIDE INTERVENTION:Duty to Warn • Would calling the parent place the child in greater danger? If so, call Children’s Protective Services. • Warning parents • Available/Cooperative? • Assessment information • Mental Health insurance • Release of information • Educate parents on depression; suicidal/self injurious behaviors; “She is doing this for attention!”

46. SUICIDE INTERVENTION:Duty to Refer • Emergency response teams • Collaborating with law enforcement • Local district resource guides • Cultural/developmental/sexuality factors • District resources (Special Ed)

47. Understanding and Responding to Students who Self-Mutilate • Very complex behavior that fulfills a multitude of needs • Dispel myths • Contagion: often runs in peer groups • Respond individually • Assess for suicide risk

48. Understanding and Responding to Students who Self-Mutilate • Warn and involve parents • Utilize school/community resources • Do not discourage self harm • Do teach substitute behaviors that focus on help-seeking/communication skills, reduction of tension and isolation