Understanding and Responding to Students who SelfMutilate RICHARD

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

Challenges to School Site Crisis Teams w Overwhelming numbers of referrals w Low risk suicide assessment w Behaviors appear contagious

Common Myths of SM Myth #1. Self-mutilators use this behavior to manipulate other people. w Myth #2. Self-mutilation is synonymous with suicide. w Myth #3. Self-mutilators are dangerous and will probably harm others. w Myth #4. Self-mutilators just want attention. w w ______________________ w Adapted from: Froeschle & Moyer (2004). Just cut it out: Legal and ethical challenges in counseling students who self-mutilate. Professional School Counseling, April, 2004.

Continuum of Self-destructive Behavior Stressors Thoughts Warning signs Behaviors SUICIDE HOMICIDE

Definitions w Inclusion of other Self-Injurious Behaviors (SIB) w Distinguish from ritual tattooing, branding and piercing w Not related to cognitive impairment

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

Classifications Of Pathological Self-mutilation w Major Self-mutilation w Stereotypic Self-mutilation w Moderate/Superficial Selfmutilation

CLASSIFICATIONS: Major Self-mutilation Infrequent act that occurs suddenly, with a great deal of tissue damage and bleeding. w Most commonly associated with psychosis and acute intoxication. w Religious or sexual themes may be present. w

CLASSIFICATIONS: Stereotypic Self-mutilation “Driven by a biological imperative to harm themselves shamelessly and without guile” Favazza Most common form: head banging w Most common population: Institutionalized/psychotic w Self-injurious behaviors (SIB) w

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.

CLASSIFICATIONS: Moderate/Superficial Self-mutilation w 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.

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

Diagnosis (2) RSM can be associated with many disorders w Borderline personality disorder w Depression: mood & anxiety disorders w Post traumatic stress disorder w

Diagnosis (3) w Impulse disorders: Episodic/gratifying • Alcohol & substance abuse • Suicide attempts • Eating disorders • Repetitive self-mutilation

RSM: Prevalence & Onset w w w Onset: late childhood-early adolescence Rates higher in adolescence: approximately 1400 per 100, 000…roughly 13% Rates higher in females Rates higher in psychiatric pop. Behaviors may become chronic and persist for 5 -10 yrs. or longer if left untreated.

RSM: Predisposing Factors w w w w Onset linked to “stressful” situations Physical/sexual abuse in childhood Family violence Early history of hospitalization/surgery Parental alcoholism/depression Perfectionist tendencies/dissatisfaction with body Inability to tolerate and express emotions

RSM: Precipitating events Chaotic families characterized by divorce, neglect or deprivation of care w Loss of a parent w • Parental loss = emotional distancing and inconsistent parental warmth Physical/sexual abuse w Having a sibling who engages in SM w Witnessing family violence w

RSM: Precipitating events (2) w w w Recent loss or death Peer conflicts Intimacy problems Break up of romance Rejection of human interconnection Fear of abandonment

Functions of SM: What Do Kids Report? Want to feel concrete pain when psychological pain is overwhelming w Reduces numbness w Keeps trauma from intruding w Gets attention of others w Discharges my anger and despair w Gain a sense of control w A way to punish myself w

Functions of SM Meets a multitude of needs w Relief from overwhelming feelings w Communication w Stop inducing or preventing dissociation w Alderman, T. (1997) The Scarred Soul: Understanding and Ending Self-Inflicted Violence (New Harbinger Press, Oakland, CA. )

Functions of SM w Self-punishment: scars/blood concrete reminders w Physical expression of pain w Re-enacting previous abuse

Functions of SM Bottom Lines Euphoric feelings w Establishing control w “Self-mutilation is an active, direct, concrete representation of intense anguish. ”

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

Phenomenology § Isolation § Engages in SM in isolation § Masks behaviors and injury with clothes § Having friends that are not friends with each other places at greater risk § Alpha teens § Borderline personality: female § Anti-social personality: male

Phenomenology § Contagion § Teens at height of imitative behavior. “rite” of togetherness § Exposure to SM and parasuicidal behavior raises risk in youth § May spread among peer groups, grade levels, clubs § Monitoring personal reactions § Caregiver’s emotional responses to SM § Caregiver responses to student § Recognize limitations

Prevention § Protective factors § Connectedness; access to mental health; spiritual life; stable families § Crisis preparation § Crisis teams; referral procedures; updating local resources (DCFS) § Training § Psycho-education § Primary prevention programs § Depressions screening; alcohol and substance abuse; bullying

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

Treatments: Biological w Serotonin (SSRIs) • Prozac, Paxil, Zoloft • Preferred treatment for depression and anxiety disorders. • Primarily affect on impulsivity/compulsivity w FDA advisory

Treatments: Psychological and Social w Making and maintaining a relationship w Breaking the habit w Maintaining change Tantam & Whitaker (1992)

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

Treatments: Cognitive/Behavioral Therapy w Connection between thoughts and behaviors • Facilitated by directing attention away from environment and towards thoughts • Replace negative perceptions with focus on positive qualities. w TADS

Treatments: Dialectical behavioral therapy Pioneered by Marsha Linehan in work with Borderline personality disorder w Combination of individual, group and skills training w Hierarchical structure of treatment goals w Success in reducing parasuicidal, SM behaviors as well as reducing behaviors that interfere with therapy w

Responding to Students who Self-Mutilate Intervention w w w Advocate and educate: Create a climate of trust with the student Legal and ethical issues Identify and refer Suicide assessment Build and tighten “Circle of Care”

Responding to Students who Self-Mutilate Intervention: Suicide assessment ASSESSMENT: LOW RISK (Ideation) w Question: Have you ever thought about suicide (harming yourself)? w Observed behaviors: current or recent thoughts or depression; direct or indirect threats, sudden changes in personality, friends, behaviors; evidence of self harm through written or art work w Actions: Reassure and supervise student; warn parent; assist in connecting with school and community resources; suicide-proof environments; mobilize a support system; utilize no-harm agreements

Responding to Students who Self-Mutilate Intervention: Suicide assessment ASSESSMENT: MODERATE RISK w Previous behaviors w Question: Have you ever tried to kill (hurt yourself) before? w Observed behaviors: previous attempts, hospitalizations, trauma (losses, victimization); recent medications for mood disorders; running into traffic, jumping from high places; RSM

Responding to Students who Self-Mutilate Intervention: Suicide assessment ASSESSMENT: HIGH RISK w Current plan and access to method w Question: Do you have a plan to kill (harm) yourself today? w Observed behaviors: current plan; finalizing arrangements by giving away prized possessions or written/e-mailed good bye notes; refusal to sign no-harm agreement

Responding to Students who Self-Mutilate Intervention: Suicide assessment ASSESSMENT: MODERATE/HIGH RISK Actions: w Supervise student (including rest rooms) w Hand off ONLY : • Parent • Law enforcement • Psychiatric mobile responder w Prepare re-entry plan.

Responding to Students who Self-Mutilate Intervention w Warning parents • Obtain relevant mental health history including insurance information; traumatic losses; victimization; signed release of information w Utilize no harm agreements w w w Connectedness with adults Help–seeking behaviors Communication skills Grief resolution Provide hotlines/websites w. Hotlines: (800) SUICIDE (800) DONTCUT w. Internet selfinjury. com selfharm. org. uk selfabuse. com Google

Responding to Students who Self-Mutilate Intervention: Tension Release Get active: Exercise w Stress management techniques w • Yoga, breathing, meditation, visualization, martial arts, Tai Chi w Alternative therapies include art and play therapy

Responding to Students who Self-Mutilate Intervention: Communication skills Help seeking behaviors w Journals/drawing to aid ventilation of emotions w Play: with younger w Advocacy: reaching out to others w Cognitive behavioral approaches w

Responding to Students who Self-Mutilate Intervention: Substitute behaviors Rubber bands w Holding books out at arms length w Standing on tip toes w Substitute ice or magic marker for sharp implement v Parent permission! w

Responding to Students who Self-Mutilate References: Lieberman, R. & Poland, S. (in press). Understanding and responding to students who self-mutilate. In G. Bear & K. Minke, Children’s needs III. Bethesda, MD: National Association of School Psychologists. w Lieberman, R. (2004). Understanding and responding to students who self-mutilate. National Association of Secondary School Principals: Principal Leadership 4(7) 10 -13. w Poland, S. & Lieberman, R. A. (2002). Suicide intervention. In Thomas, A. & Grimes, J. , Best practices in school psychology IV. Bethesda, MD: National Association of School Psychologists. w w nasponline. org