S.A.F.E. ALTERNATIVES ®

1. S.A.F.E. ALTERNATIVES® Michelle Seliner MSW,LCSWChief Operating Officer800-DONTCUT® (366-8288) selfinjury.com

2. What is S.A.F.E. ALTERNATIVES®? • Self-Abuse Finally Ends (S.A.F.E.) • Founded in1986 as the first specialty program for the treatment of self-injury. • An internationally recognized treatment approach, professional network and educational resource base committed to helping people achieve an end to self-injurious behavior.

3. Founders Karen Conterio and Wendy Lader, Ph.D. in 1984 Authors of: Bodily Harm: The Breakthrough Healing Program for Self-Injurers, (Hyperion, 1998) Daño Corporal, (Virgin Ink Press, 2008) S.A.F.E. Focus: A Self-Help Group Manual (V.I.P, 2007) Self-Injury: A Manual for School Professionals & Student Workbook (Virgin Ink Press, 2008). Numerous works in professional journals Dr. Lader lectures internationally and is a founding member of the ISSS.

4. DELIBERATE SELF HARM PARASUICIDE (“like suicide”) SELF ABUSE SELF MUTILATION “CUTTERS” NSSI (Non Suicidal Self-Injury) SELF-INJURY: AKA

5. “The deliberate mutilation of the body, or a body part, not with the intent to commit suicide but as a way of managing emotions that seem too painful for words to express” …Bodily Harm1998 Definition

6. Cutting Burning Head banging Biting Interfering with wound healing Trichotillomania Facial picking/skinning Ingesting/ Injecting sharp objects or toxic substances Breaking bones Amputation/ Blinding Scratching/ Excoriation Examples of Self-Injury

7. Prevalence of Self-Injury • It is estimated that 4% of the adult general population admits to at least occasional self-injury (Briere & Gil, 1998). • A recent research study of 2,875 college students showed a lifetime prevalence of 17% have engaged in NSSI (Whitlock, 2006). • A study of 633 H.S. students showed that almost half had engaged in some form of NSSI and 60% of those were moderate/severe (Lloyd-Richardson, 2007).

8. Self-Injury and Suicide • Approximately 55%-85% of self-injurers have made at least one suicide attempt (Stanley, B., Gameroff, M.A. Michalsen, B.A., & Mann, M.D., 2001). • Self-injurers are nine times more likely to kill themselves than non self-injurers. • 28%-41% of individuals who engage in self-injurious behaviors report suicidal thoughts at the time of the episode of self-harm (Favazza, 1998, Paterson and Kahan).

9. Self-injurers tend to misperceive the severity of their attempts. They believe more strongly that they would be rescued, that death would be less likely if they received medical attention, and that death was a sleep-like state or a reunion with their ancestors. (Stanley, B., Gameroff, M.A. Michalsen, B.A., & Mann, M.D., 2001). Self-Injury and Suicide

10. Self-injurers can kill themselves accidentally. This is the number one reason given for motivation to attend the S.A.F.E. program. Self-injurers can become hopeless when their coping strategy fails to work or their stressor is perceived to be too large. They can then choose suicide as an option. Self-Injury and Suicide

11. Where did they injure? What do they tell you about their intent? Did they use their usual method of injury? *It’s important to note that 98.6% of people who die by suicide use methods other than cutting (guns, hanging, overdose, jumping etc). {Statistics from the CDC as reported in Walsh 2006} Differentiating Self-Injury from Suicide

12. Emotional Regulation: * Palliative Aims: Calm fears and anxiety * Survival: to survive annihilative fear * Analgesic: Numbing * To Feel Something: Counteract numbing / dissociation Purposes of NSSI

13. Religious Themes: *Self-sacrifice *Overcome one’s body * Self-punishment

14. Communicative Aims Skin: “ Where do I begin and end?” Bulletin Board: Is body art a form of self-injury? Belongingness:“Who I am? (group, rank)

15. CULTURAL FAMILIAL BIOLOGICAL

16. Disenfranchised Society Collapse of Extended Family Emphasis on “Quick Fix” “A-holic Society” Increase in individualized activities Differences Body Focused Culture

18. Divorce Strangers baby sit Latch key kids Dinner no longer sacred Loss of rites of passage Loss of mentoring

22. Loneliness and Isolation In 1985, the average American had three people in whom to confide matters that were important to them, says a study in American Sociological Review. In 2004, that number dropped to two, and one in four had no close confidants at all (USA Today, 6/2004).

23. LGBT Weight issues Physical Infirmity/Chronic Illness Learning Disabilities Sexual /Physical Abuse Parental Maltreatment Adoption Perception of being different/inadequate

24. Body Focused Culture

25. Sexual Abuse Distorted belief: Ugliness will protect me. ~Reality: puts one on the fringe of society and thus more vulnerable. Rape is a crime of power, not sex. Objectification of the Body: Make the outside look like the inside. The body becomes a split off part that becomes the focus of hate. Sexuality represents adulthood, with adult responsibilities.

26. Understanding the relationship between Eating Disorders and Self-Injury….. Body Focused Behaviors

27. A study of 376 inpatient women being treated for an Eating Disorder found that 34.4% has self-injured at some point in their life (Paul et.al, 2002) Studies of self-injurers have reported statistics ranging from 50%- 60% (Favazza et. al., 1989; Walsh & Frost, 2005) NSSI and Eating Disorders

28. CONTROL: Both master what others can’t. “Tough enough to handle pain” “Tough enough to conquer hunger” PROTECTION: Both interfere (take the place of/protect from) social activities PURGE: Both rid one of toxic feelings that are symbolized by food and blood BODY OBJECTIFICATION : The body becomes the the displaced object for hate. Self-Injury and Eating Disorders

29. 34% strongly hate their bodies 58% hate their periods 56% hate pelvic exams 19% believe they’d be better without a vagina 10% injure in an attempt to stop their periods Self-Injury and Body Image

30. Intrauterine environment: Stress/ Substance Abuse Post Natal: Critical Period? Russian orphanages Temperament: Genetically Predetermined? Biology

31. Twin studies at U.of Mn. (Drs.Lykken & Tellegen) were able to predict happiness scores of twins reared apart with almost 100%accuracy. Dr. Ed Diener (U. of I Urbana) estimates that 50% of happiness is genetic and the other half is “modifiable within limits.” Biology

32. Preliminary Interventions Helping to prepare clients for treatment

33. Before one can truly work with a self-injurer it would be helpful to be on the same page. As the behavior becomes more common it is not hard to find peer support for this belief system. *New Cornell study. Many self-injurers believe that the behavior is a valid coping strategy and that they need it to survive. Denial

34. “Self-Injury doesn’t hurt anyone” “I don’t understand why it upsets others” “It’s my body and I can do what I want with it” “I’d rather hurt myself than someone else” “Giving up self-injury will only make me hurt more” Challenge Irrational Thoughts

35. “The scars remind me of the battle” “It’s the best way for others to see my pain” “No one knows that I injure anyway” It keeps people away” “It’s the only way to know if people care about me” IrrationalThoughts

36. Begins with the assumption that, although temporarily helpful, self-injurious behavior is ultimately a dangerous and futile coping strategy which interferes with intimacy, productivity, and happiness. There is no “safe” or “healthy” amount of self-injury. That self-injury is not an addiction over which one is powerless for a lifetime. Self-injury can be transformed from a seemingly uncontrollable compulsion to a choice. S.A.F.E. Philosophy

37. Matthew K. Nock, Ph.D. John L. Loeb Associate Professor of the Social Sciences Department of Psychology, Harvard University Outcome Research

38. SUBJECTS: Participants were 123 adolescents and adults who consecutively presented for treatment at the S.A.F.E. ALTERNATIVES® Intensive Treatment Program between 1996 and 2000. Participants were 91.1% female and ranged in age from 12 to 57 years (M = 30.8, SD = 9.3). RESULTS: Analyses revealed that each of the 11 forms of self-injury assessed decreased significantly from admission to three-month follow-up with effect sizes that were medium to large in magnitude (Cohen’s ds = 0.46 to 1.72). These changes were maintained at 12-month follow-up for all 11 forms of self-injury. One form of self-injury (self-poisoning) decreased further from three- to 12-month follow-up (Cohen’s d = .52). Outcome Study Results

39. Outcome Study Results Decrease in Subsequent Medical Hospitalization Participants reported significant decreases in medical hospitalizations from admission to 3 and 12 month follow-up. This would indicate that severity of self-injurious behavior decreased as well. Increase in the Use of Adaptive Coping Skills There was a reported increase in the use of family support, therapist support, journaling, positive distractions, and controlling urges. These significant increases were large with effect sizes ranging from .50 to 2.08.

40. S.A.F.E. PROGRAMS • S.A.F.E. Intensive®: Exclusive 30 day residential program • S.A.F.E. Expressions®: PHP and IOP • S.A.F.E. Choice®: Outpatient group psychotherapy

41. S.A.F.E. INTENSIVE™ • A 30-day comprehensive treatment program for clients age 12 through late adulthood who engage in repeated self-injurious behavior.  The treatment program is approximately 30 days of residential programming based upon the individual needs and treatment plan of each client. • The multidisciplinary treatment team uses individual, group, and family therapies to support and empower individuals to make healthier choices when dealing with emotional distress. The program is voluntary and therefore, clients must be motivated to stop the self-destructive behavior.

42. Evenings are traditionally the most difficult time for self-injurers Fear that if they give up the behavior something terrible will happen. Outpatient provides minimal support for all but, on average, 45 minutes a week Inpatient has the advantage of approaching the issues from a myriad of therapeutic modalities, pushing the intensity of the process which allows clients to practice experiencing intensive feeling states within a therapeutic holding environment Why Residential?

43. S.A.F.E. EXPRESSIONS® • S.A.F.E. Expressions® differs from S.A.F.E. Intensive® in the following way: • Inpatient criteria require that the client has made an honest commitment to want to stop self-injurious behavior. S.A.F.E. Expressions® criteria allows for ambivalence towards having an honest commitment to stopping self-injurious behavior. The goal is to stop self-injury. However, for many, the focus will be on getting the client to the point of making that commitment. • S.A.F.E. Intensive® has a structured manner in which self-injury within the program is addressed; whereas S.A.F.E. Expressions® will encourage clients to not self injure and will assess the client for a more acute level of care if self injurious behavior continues and interferes with their treatment or the treatment of their peers.

44. S.A.F.E. CHOICE® • A once a week outpatient group psychotherapy program that is offered in six-week segments.  Clients can opt to join as many segments as they choose. Appropriate candidates are adolescents and adults who self-injure and want to change the behavior.  • Participants may have attended one of the S.A.F.E. ALTERNATIVES® Programs; however it is not a requirement.  Group size is limited, and the group is generally closed.  Separate groups can be offered for adults and adolescents, and each is facilitated by a Licensed Clinical Therapist.  All participants are encouraged to be in outpatient individual and/or family therapy and will be required to sign the S.A.F.E. Choice® Promise and group contract.

45. Goals for Intervention Treatment without goals is like shooting in the dark… you just hope you hit your target.

46. To get through defenses to core affect. To help client identify and communicate experiences to others verbally, in an age appropriate manner. To challenge irrational thoughts To learn to differentiate thoughts , feelings and behaviors. Increase the “Window of opportunity” between an impulse (thought) and an action (behavior). Goals for Intervention

47. To experience a feeling (anger) without an action (violence). To face fears directly, and to challenge irrational thoughts, rather than running from/ medicating with self-injury. To mourn the loss of the idealized childhood. Goals for Intervention

48. Treatment Participation Agreement Alternatives Feelings List Impulse Control Logs Writing Assignments Individual/Family Therapy S.A.F.E. ALTERNATIVES ®TOOLBOX

49. Not Recommended:Substitute Behaviors SNAPPING RUBBER BANDS PUTTING HANDS IN ICE H2O DRAWING ON BODY WITH RED MAGIC MARKER BREAKING AN EGG OVER THE SKIN TO SIMULATE BLOOD

50. Supports our belief in our clients strengths Sends message to think before acting Won’t collude with escape through self-medication Contagion D/C confirms that SIB brings about loss Same policy as drug & ETOH treatment No Harm ContractResidential Treatment Only