Self-Injurious Behavior in Adolescents

1. Self-Injurious Behavior in Adolescents WJCIA Annual Training Conference Stevens Point September 28, 2007

2. Kay F. Heimerl, MS LCSW Outagamie County DHHS heimerkf@co.outagamie.wi.us (920)832-5270

3. Self Injurious Behavior How will you know I’m hurting If you cannot see my pain? To wear it on my body Tells what words cannot explain. - C. Blount

4. Definition: • An injury to one’s own body, done without suicidal intent or intent to attain sexual gratification. • Self-inflicted harm is enough to cause tissue damage. • Not part of spiritual ritual or for ornamental purposes. • Done as a way to alter a perceived intolerable mood state.

5. Demographics • 3 million Americans • 1% of the general population • Males and Females • Middle class and educated • History of abuse and/or trauma • Often starts in early teens, peaks from ages 18-24, decreases in 30’s and 40’s

6. Methods of SIB • Cutting • Burning • Scratching • Picking • Interfering with wound healing • Head banging • Hitting self

7. Methods of SIB cont… • Breaking bones • Hair pulling • Spooning • Eating harmful objects – lightbulbs, glass, plastic • Ingesting chemicals • Over/under eating

8. Comorbid behaviors • Reckless driving • Unprotected sex • Shoplifting • Promiscuity • Substance abuse • Eating disordered behavior

9. Wound Severity • Extent of the damage • Level of medical intervention required • Location of the wound

10. High Risk Groups • Emotionally disturbed children • History of trauma/abuse • Borderline Personality Disorder • Young males with psychosis • Gender identity disorders • Dissociative disorders

11. High Risk Groups cont… • Substance abusers • Teens whose parents are physically or emotionally unavailable to them • Teens with untreated depression or anxiety

12. . Why do people self injure?

13. Because it works!!!All self-injury is designed to feel good at that moment.

14. Purpose of SIB • Relief from psychological pain • Release of tension • Affect regulation – can’t feel, feel too much • Communicate feelings – anger, sadness, pain, etc.

15. Purpose of SIB cont… • Way of being in control • Defense mechanism • Feel the need to be punished • To be unattractive • Endorphins of physical pain cover up the emotional pain • “Event marker”

16. Attention seeking??? • Not usually • Sometimes done to induce rescuing behaviors in others • Can provide an opportunity for self-care afterwards

17. Actually it is often under-diagnosed and under-reported due to: Shame, guilt, fear, pride Learned distrust of others Fear of legal consequences Mixed feelings about treatment/recovery Attention Seeking???

18. SIB is often preceded by one or more of these emotional factors: • Depression • Stress • Hopelessness • Powerlessness • Purposelessness • Anxiety • Fear

19. Psychological characteristics of Self Injurers • Invalidate self • Hypersensitive to rejection • Pervasive anger • Tend to suppress anger • Impulsive • High levels of aggressive feelings • Act on immediate mood

20. Psychological characteristics cont . . . • Feel powerless over how or whether they cope with life • Not future-focused • Depressed/suicidal/self-destructive • Anxious • Lack of coping skills • Avoidant

21. How should we react? • Don’t ignore it! • Always take it seriously. • Don’t judge! • Show concern. • Stay calm and sincere. • Don’t overreact, rescue or “hyper-nurture”.

22. How should we react? • Remember that it is a cry for help. • Find out what is going on beneath the behavior. • Listen! Listen! Listen! • Don’t punish! Any interventions should be designed to protect, not to punish. • Acknowledge the SIB as a survival strategy.

23. How should we react? • Assess the extent of the injury and intervene appropriately. • Let them know that it is OK to talk about their SIB. • State that you cannot talk to the person while they are injuring because you care about them and it hurts you to see that.

24. How should we react? • Do not use ultimatums – i.e. stop or else! • Set reasonable limits.

25. Interventions/Referrals: You must find something to replace the behavior. You can’t just take it away.

26. Interventions/Referrals: • Psychotherapy – many methods and interventions • Trauma work – therapy, PTSD Workbook, EMDR • Contracts – agree to try alternate behaviors before SIB • Alternate behaviors need to be harm reducing – rubberband snapping, hands in ice, chewing cinnamon or hot peppers, etc.

27. Interventions/Referrals: • Medication • Develop Personal Validation • Spirituality • Meditation • Yoga, Tai Chi • Appropriate physical releases

28. Interventions/Referrals: • Group therapy – DBT, Abuse survivors • Family therapy • Change core beliefs and values • Teach emotional literacy – feeling lists, journaling • Safety bag

29. Safety Planning • Assessment questions • Do you need to hurt yourself? What has brought you to this point? • Have you been at this point before? What did you do then to deal with it? How did you feel then? • What have you done to ease this discomfort in the past? What else can you do that won’t hurt you?

30. Safety Planning • Assessment questions cont… • How do you feel right now? • How do you feel after hurting yourself? How will you feel tomorrow morning? • Can you avoid this stressor, or deal with it better in the future?

31. Safety Planning • Contracts • List alternate behaviors to use before SIB • Names and numbers of contact persons • When to call Crisis • When to seek medical attention • Discuss placement options ahead of time if possible – i.e. hospital, crisis bed, secure detention, family member, etc.

32. Safety Planning • Decide who will be included in the contract – parents, school personnel, mentor, physician, etc. • Determine length of contract viability • Be clear about mandatory reporting obligations and potential consequences • Consult with Mental Health professional

33. QUESTIONS???