Presentation on theme: "Working with Self-injurious Youth in Schools NYASP 2014"— Presentation transcript:
1 Working with Self-injurious Youth in Schools NYASP 2014 Steve Hoff, Licensed PsychologistAssociate Professor of School Psychology,The College of Saint Rose, Albany NY
2 Amazing AlbanyTHE ALBANY-SCHENECTADY RAILROAD, THE OLDEST IN THE UNITED STATESThe 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
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) DefinitionsThe direct, deliberate destruction or alteration of one’s own body tissue without conscious suicidal intentFavazza, Bodies under siege (1987)Self-mutilative behavior is deliberate, non- life-threatening, self-effected bodily harm or disfigurement of a socially unacceptable natureWalsh & Rosen, Self-mutilation: Theory, research and treatment (1988)
17 Prevalence 4% of general adult population 21% of clinical populations 12% - 38% of college and high school studentsWhitlock & Knox, Archives of Pediatric Adolescent Medicine (2007)Prevalence by gender11 year study of adolescents 12 – 18487 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 1:2Hawton, 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)
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 developmentBody image - Cultural/media images and expectationsAuthority - Children start to pull away. Less idealized view of parentsPeers - 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 experimentationInconsistent judgment – Thinking and judgment are at times brilliant and at times notPersonality changes – Introspection, egocentrism, self-consciousness, moodiness
24 MotivesEmotional distress. The self-injurer is seeking relief – emotion regulationDepressionAlienationIdentity issuesGrief/lossAbuse
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% Anxious76%30%14%Calm6%45%72%Confused63%29%28%Clear-headed11%34%47%Depressed88%39%36%Elated4%22%19%Internet survey of adolescent self-injurers. Murray, Warm and FoxAustralian e-Journal for the Advancement of Mental Health (2005)n=128
28 Brain Function and Psychopharmacology Brain systems involved in self-injuryLimbic system: regulates mood/affect and painDopaminergic systemsSerotonergic systemsHypothalmus/pituitary/adrenal axisStudies suggest many systems involved – not a single pathway
29 Brain Function and Psychopharmacology (continued) Many different medications are used to treat:AntidepressantsSSRIs (Prozac, Zoloft)Antipsychotics (Abilify, Zyprexa, Risperdal, Clozaril)Mood stabilizers (Depakote, Tegretol, Lithium, Topomax)Anxiolytics (Ativan, Valium)No medication intervention is well establishedMust consider long term vulnerability and development, and current contextHarper 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 CareIntervention/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 symptomsSuicidal ideationSocial supportSelf-esteemBody satisfactionDisordered eatingBrausch 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-injuryParents must be part of a clear support plan and must follow through on responsibilities re: outpatient careFamily 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-injuryWhere 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 reportWhat is self-injury?What should staff be on alert for?Pay attention in ‘hot spots’ in the school: lunchroom, schoolyard, bathroom, gymWho should staff tell? School psychologist, guidance counselor, social worker, nurse, administrator, etc.
37 Warning Signs - Behavioral Other self-destructive behavior (substance abuse)Depression/emotional negativityPoor self-esteemMiller & Brock - Identifying, Assessing, and Treating Self-Injury at School (2011)Risky sexual practicesPossession of things that could be used for cuttingLieberman 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 accidentalFrequently bandaged wrists and armsReluctance to change clothes or participate in gymWearing long sleeves in hot weather
39 School – Contagion Reasons for self-injury contagion Peer connectedness and identityCompetition to be ‘the real cutter’Expression and communication of feelingsResponse to manage contagionIndividualize and contain – divide and conquerEngage self-injurers, individually, in meaningful ways, e.g. sports, arts, being a helper, USE THE RELATIONSHIPBuild system-wide support plan: family, community, etc. for each individual studentMay have to implement disciplinary response – limit set
40 School - Services Individual Groups Family work – when appropriate Support work in school, intensive work with outpatient clinicianGroupsProblem solvingSelf-esteem buildingStress managementSocial skills training/building peer relationshipsCAREFUL with groups around cuttingActivitiesSportsThe Arts: Music, Drama, Visual Arts, DanceAdventure Based Counseling groupsTherapeutic animal contactFamily work – when appropriate
42 TREATMENT CONSIDERATIONS Do’s! Think strengths (Brooks – “Islands of Competence”)Get the child to express her feelingsAcknowledge that she is hurting and that cutting is her way of copingTreat her with respect, express your belief that she is capable and worthy of self- respect, able to be responsible and in controlBe willing to talk about specifics of cutting & what’s behind itTalk about alternatives to cutting
43 TREATMENT CONSIDERATIONS Don'ts! Think illness/pathologyAssume that she is cutting to get attentionBe shocked, angry, disgusted, disapprovingMinimize the importance that cutting holds for herPower Struggle
44 Treatment Attachment and Corrective Emotional Experience History of conflict in relationshipsDifficulty having healthy connectionsFew, if any, positive relationships with adultsRelationship with YOU can change her perception of what relationships CAN BE
45 The RelationshipSix personality traits necessary to help a teen in crisis:Confidence UnderstandingEmpathy NurturingKnowledge OptimismSteven Levenkron, Cutting, understanding and overcoming semutilation (1998)
46 “The body keeps the score” (van der Kolk,1996) Body Based Therapies“The body keeps the score” (van der Kolk,1996)
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 togetherPractice happens in the real world and the results are brought back in to the work
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 cannotCan use scales. Beck Depression Inventory, etc.Ask directly about suicide/intentDetermine level of risk: low, moderate, highDetermine treatment setting and planMultiple attempters at much greater riskM. 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 disputesFamily and community supportAccess to effective and appropriate mental health care and support for help-seekingRestricted access to highly lethal methods of suicideCultural and religious beliefs that discourage suicide and support self-preservation instinctsNational Youth Violence Prevention Center (2004)
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 wayManage our own stressMindfulness, relaxation, alonetime, exercise, etc.