1. Working with Self-injurious Youth in Schools NYASP 2014
Steve Hoff, Licensed Psychologist
Associate Professor of School Psychology,
The College of Saint Rose, Albany NY

2. Amazing Albany
THE ALBANY-SCHENECTADY RAILROAD, THE OLDEST IN THE UNITED STATES
The Mohawk and Hudson Company – in the first passenger train in America was run over sixteen miles from Albany (intersection of Madison and Western Aves) to Schenectady

3. According to the US patent office, Seth Wheeler of Albany patented what was called perforated wrapping paper ("toilet" was a sensitive word in 1871). He patented the idea to have the product wrapped around a central tube in 1891, and is also often credited with patenting a bracket to hold those tubes.

4. Self-Injury in Pop-Culture
Google hits for ‘self-harm’
October 2014 – 3,020,000

5. Goth Culture

6. Google Images hit for “Emo”

7. Luv-Emo Website – Pics Boys

8. Luv-Emo Website – Pics Girls

9. Barbie

10. Italy Fashion Industry – Considering
Skinny Model Ban, 2006

11. Liposuction – Online Ad for Plastic Surgery Practice

12. Walsh & Rosen, Self-mutilation: Theory, research and treatment (1988)
Definitions
The direct, deliberate destruction or alteration of one’s own body tissue without conscious suicidal intent
Favazza, Bodies under siege (1987)
Self-mutilative behavior is deliberate, non- life-threatening, self-effected bodily harm or disfigurement of a socially unacceptable nature
Walsh & Rosen, Self-mutilation: Theory, research and treatment (1988)

13. Knife Inflicted Wounds

14. Eraser Burns

15. Plastic CD Cover “Carving”

16. Cigarette Burns

17. Prevalence 4% of general adult population 21% of clinical populations
12% - 38% of college and high school students
Whitlock & Knox, Archives of Pediatric Adolescent Medicine (2007)
Prevalence by gender
11 year study of adolescents 12 – 18
487 males, 1633 females (70% female) – but more male cutting likely
-at 12 years, M:F ratio was 1:8
-at 18 years, M:F ration was 1:2
Hawton, Journal of Child Psychology and Psychiatry (2003)
“Unfortunately, many middle schools and high schools in the US are experiencing an explosion of self-injury among their students”
Walsh, Treating self-injury (2006)

18. Why Self-injury?

19. Perfect

20. Case Formulation How do I understand the presenting problem?
What is the WHY behind the behavior(s)?
What is the Intervention?

22. Normal Adolescent Development

23. Middle school Adolescents What to expect:
Puberty - It comes, but on a variable timetable. Some kids mature early, some late. Boys – body hair, change of voice; Girls – menstruation, breast development
Body image - Cultural/media images and expectations
Authority - Children start to pull away. Less idealized view of parents
Peers - Increasingly important. Bullying and cliques can increase
“Finding their Tribe” - Looking for belonging and meaning. “Where do I fit in”? Social groups, rejection, popularity.
Risk taking – Increases. Smoking, drugs, sexual experimentation
Inconsistent judgment – Thinking and judgment are at times brilliant and at times not
Personality changes – Introspection, egocentrism, self-consciousness, moodiness

24. Motives
Emotional distress. The self-injurer is seeking relief – emotion regulation
Depression
Alienation
Identity issues
Grief/loss
Abuse

25. Motives (continued)
“NSSI functions as a means both of regulating one’s emotional/cognitive experiences and of communicating with or influencing others”
Nock, Why do people hurt themselves? New insights into the nature and functions of self-injury (2009)

26. Emotional State Emotion Before During After 76% 30% 14% 6% 45% 72% 63%
Anxious
76%
30%
14%
Calm 6%
45%
72%
Confused
63%
29%
28%
Clear-headed
11%
34%
47%
Depressed
88%
39%
36%
Elated 4%
22%
19%
Internet survey of adolescent self-injurers. Murray, Warm and Fox
Australian e-Journal for the Advancement of Mental Health (2005)
n=128

28. Brain Function and Psychopharmacology
Brain systems involved in self-injury
Limbic system: regulates mood/affect and pain
Dopaminergic systems
Serotonergic systems
Hypothalmus/pituitary/adrenal axis
Studies suggest many systems involved – not a single pathway

29. Brain Function and Psychopharmacology (continued)
Many different medications are used to treat:
Antidepressants
SSRIs (Prozac, Zoloft)
Antipsychotics (Abilify, Zyprexa, Risperdal, Clozaril)
Mood stabilizers (Depakote, Tegretol, Lithium, Topomax)
Anxiolytics (Ativan, Valium)
No medication intervention is well established
Must consider long term vulnerability and development, and current context
Harper in Walsh, Treating self-injury (2006)

30. School School must have a clear protocol for managing self-injury
Must be informed by a systems-wide approach

31. Self-injury/Suicide Risk Assessment Flow Chart
Level of Care
Intervention/Services

32. The Risk…
“Even though most cases of DSH do not end in overt suicide, DSH reflects that potential underlying psychological pathophysiology, and likelihood of eventual death from self-murder, cannot always be predicted or prevented. It is important to take all acts of DSH as serious, and to offer comprehensive management to prevent future acts of DSH and potential suicide”.
Greydanus and Apple, The relationship between deliberate self-harm behavior, body dissatisfaction, and suicide in adolescents (2011)

33. Differences in NSSI and Suicide Attempts in Adolescents
Depressive symptoms
Suicidal ideation
Social support
Self-esteem
Body satisfaction
Disordered eating
Brausch and Gutierrez, Differences in Nonsuicidal self-injury and suicide attempts in adolescents (2010)

34. Parents/Family Work Parents must be notified
Parents must be educated about self-injury
Parents must be part of a clear support plan and must follow through on responsibilities re: outpatient care
Family therapy may be indicated if family issues are a key component

35. School - Assessment What is the level of risk?
Question student about the frequency, duration, intensity of self-injury
Where does the self-injury occur – school, home, other?
Other dangerous behaviors? Drugs, risk taking, etc.
Suicidal intent?
What is the level of peer involvement and need for follow-up?

36. School – Staff Training
Train staff to recognize and report
What is self-injury?
What should staff be on alert for?
Pay attention in ‘hot spots’ in the school: lunchroom, schoolyard, bathroom, gym
Who should staff tell? School psychologist, guidance counselor, social worker, nurse, administrator, etc.

37. Warning Signs - Behavioral
Other self-destructive behavior (substance abuse)
Depression/emotional negativity
Poor self-esteem
Miller & Brock - Identifying, Assessing, and Treating Self-Injury at School (2011)
Risky sexual practices
Possession of things that could be used for cutting
Lieberman et al. (2009) Non-suicidal self-injury in the schools: Prevention and intervention. In Nixon & Heath Self-injury in youth: The essential guide to assessment and intervention.

38. Warning Signs - Physical
Scratches or burns that don’t appear accidental
Frequently bandaged wrists and arms
Reluctance to change clothes or participate in gym
Wearing long sleeves in hot weather

39. School – Contagion Reasons for self-injury contagion
Peer connectedness and identity
Competition to be ‘the real cutter’
Expression and communication of feelings
Response to manage contagion
Individualize and contain – divide and conquer
Engage self-injurers, individually, in meaningful ways, e.g. sports, arts, being a helper, USE THE RELATIONSHIP
Build system-wide support plan: family, community, etc. for each individual student
May have to implement disciplinary response – limit set

40. School - Services Individual Groups Family work – when appropriate
Support work in school, intensive work with outpatient clinician
Groups
Problem solving
Self-esteem building
Stress management
Social skills training/building peer relationships
CAREFUL with groups around cutting
Activities
Sports
The Arts: Music, Drama, Visual Arts, Dance
Adventure Based Counseling groups
Therapeutic animal contact
Family work – when appropriate

41. CLINICAL INTERVENTION

42. TREATMENT CONSIDERATIONS Do’s!
Think strengths (Brooks – “Islands of Competence”)
Get the child to express her feelings
Acknowledge that she is hurting and that cutting is her way of coping
Treat her with respect, express your belief that she is capable and worthy of self- respect, able to be responsible and in control
Be willing to talk about specifics of cutting & what’s behind it
Talk about alternatives to cutting

43. TREATMENT CONSIDERATIONS Don'ts!
Think illness/pathology
Assume that she is cutting to get attention
Be shocked, angry, disgusted, disapproving
Minimize the importance that cutting holds for her
Power Struggle

44. Treatment Attachment and Corrective Emotional Experience
History of conflict in relationships
Difficulty having healthy connections
Few, if any, positive relationships with adults
Relationship with YOU can change her perception of what relationships CAN BE

45. The Relationship
Six personality traits necessary to help a teen in crisis:
Confidence Understanding
Empathy Nurturing
Knowledge Optimism
Steven Levenkron, Cutting, understanding and overcoming se
mutilation (1998)

46. “The body keeps the score” (van der Kolk,1996)
Body Based Therapies
“The body keeps the score” (van der Kolk,1996)

47. Therapeutic Approaches
Rational Emotive Behavior Therapy
Albert Ellis
Dialectical Behavior Therapy
Marsha Linehan

48. Therapeutic Approaches (cont’d)
Wisdom/Compassion/Mindfulness
Self-compassion
Wisdom and Compassion in Psychotherapy
Germer & Siegel (2012)

50. REBT Strategies DIBs – Dispute Irrational Beliefs
Double Standard Dispute – “what if this were your friend’s problem?”
Catastrophe Scale- “0 is resting at home, 100 is being shot”
Reframing – “not devastating, upsetting” or “what are the positives of this situation?”
Blow-up Technique – combined with humor – blow out of proportion to show irony, have client laugh at their fear

51. REBT - Homework MUST use homework in REBT
Student practices what you came up with together
Practice happens in the real world and the results are brought back in to the work

52. REBT Practice Time
Activity

53. DBT Try to change AND try to Radically accept Mindfulness
Interpersonal Effectiveness
Emotion Regulation
Distress Tolerance
Linehan – Treating BPD (1993)

54. Behavioral Tech

55. Breath

57. Interpersonal Effectiveness

58. Emotion Regulation

59. CAT EMOTION CHART

60. Distress Tolerance…
The Senses

61. Jen and the Cardinal

63. PROS AND CONS Destructive behavior I wanted to do: __________________
Tolerating distress PROS
__________________
NOT tolerating distress PROS
Tolerating distress CONS
__________________
NOT tolerating distress CONS

64. Suicide Risk

65. Suicide Risk Assessment
Multiple contributing factors to consider:
Conduct a thorough psychiatric exam, indentifying risk factors and protective factors and distinguishing risk factors that can be modified from those that cannot
Can use scales. Beck Depression Inventory, etc.
Ask directly about suicide/intent
Determine level of risk: low, moderate, high
Determine treatment setting and plan
Multiple attempters at much greater risk
M. David Rudd, Ph.D. Treating Suicidal Behavior (2001)

66. Suicide Risk Assessment Protective Factors
Learned skills in problem solving, impulse control, conflict resolution, and nonviolent handling of disputes
Family and community support
Access to effective and appropriate mental health care and support for help-seeking
Restricted access to highly lethal methods of suicide
Cultural and religious beliefs that discourage suicide and support self-preservation instincts
National Youth Violence Prevention Center (2004)

67. C-SSRS

68. Taking Care of the Caregiver: This Means YOU!
Seeing self-injury, and the results, can be shocking, even sickening – it is okay to feel this way
Manage our own stress
Mindfulness, relaxation, alonetime, exercise, etc.