1. Cutting: Understanding and Addressing Self-Injury Alpine School District School Counselors, April 1, 2014 Michael Riquino, LCSW

2. What is Self-Injury?  Deliberate or intentional destruction of body tissue without suicidal intent  Other common labels include deliberate self- harm, parasuicidal behavior, self-mutilation, non-suicidal self-injury, and cutting (Gratz, 2003; Klonsky, 2007; Klonsky & Muehlenkamp, 2007; Nock, Teper, & Hollander, 2007)

3. Forms of Self-Injury Most common forms:  cutting (70-97%)  banging or hitting (21-44%)  burning (15-35%)  75% of individuals who engage in self-injury employ more than one method Other forms include:  bone breaking  skin picking (dermatillomania)  hair pulling (trichotillomania)  biting and scratching  interfering with the healing of wounds (excoriation) (Klonsky, 2007; Conterio, Lader, & Bloom, 1998; Strong, 1998)

4. Prevalence of Self-Injury  9% - 17% of adolescents in community samples  28% - 46% of high school students reported at least one instance of self-injury in the last year  40% - 80% of adolescent psychiatric patients  Average age of onset between 12 and 15 years old ( as young as 6 and up to 24 ) (Klonsky, 2007; Hollander, 2008; Strong, 1998; Klonsky & Muehlenkamp, 2007; Nock, Teper, & Hollander, 2007)

5. Myths, Misconceptions, and Misunderstanding

6. Myths regarding Self-Injury Myth: Children and adolescents self-injure to get attention Truth: Less than 4% of adolescents who self-injure do so to get attention, yet this is the most common reason given by parents, teachers, and other adults to explain the behavior

7. Functions of Self-Injury Most common functions:  Emotion regulation  Anti-dissociation  Anti-suicide  Self-punishment  Interpersonal influence Other functions include:  Sense of control  Connecting mind and body  Sensation-seeking  Avoidance of internal pain  Distraction from flashbacks (Conterio, Lader, & Bloom 1998; Gratz, 2003; Klonsky, 2007; Klonsky & Muehlenkamp, 2007; Polk & Liss, 2009)

8. Myths regarding Self-Injury Myth: Children and adolescents who self-injure are just crazy Truth: Although self-injury is highly correlated with a variety of mental illnesses, most individuals who self- injure have experienced some form of trauma

9. Self-Injury and Mental Illness Self-injury is diagnostically heterogeneous:  Mood disorders ( depression, bipolar)  Anxiety disorders (GAD, PTSD )  Personality disorders ( borderline, avoidant)  Eating disorders ( bulimia, anorexia )  Substance disorders (Conterio, Lader, & Bloom, 1998; Hollander, 2008; Klonsky, 2007; Klonsky & Muehlenkamp, 2007; Nock, Teper, & Hollander, 2007; Strong, 1998)

10. Myths regarding Self-Injury Myth: Individuals who engage in self-injury are teenage girls who have been sexually abused Truth: Studies have found similar rates of self-injury among males and females, although there is a correlation between self- injury and child abuse

11. Self-Injury and Child Abuse  62% of individuals engaging in self-injury report some form of childhood abuse  50-59% report child sexual abuse  Perhaps 5% of the variance in the development of self- injury can be attributed to child sexual abuse  Sexual abuse and self-injury might be associated because they are correlated with the same psychiatric risk factors such as depression, anxiety, and feelings of low self-worth (Conterio, Lader, & Bloom, 1998; Klonsky and Moyer, 2008; Klonsky & Muehlenkamp, 2007; Lang & Sharma-Patel, 2011; Spinhoven, Slee, Garnefski, & Arensman, 2009; Strong, 1998)

12. Myths regarding Self-Injury Myth: Self-injury is a failed suicide attempt Truth: Although individuals who self-injure are at risk for suicidal thoughts and gestures, self-injury often serves as a coping mechanism for dealing with suicidal ideation

13. Self-Injury and Suicide  50% of individuals in community samples and 70% of inpatients who engage in self-injury report having attempted suicide at least once  A paradoxical relationship:  self-injury simultaneously serves as a coping mechanism for dealing with suicidal ideation and is a correlate of past and possible future suicide attempts (Conterio, Lader, & Bloom, 1998; Hollander, 2008; Klonsky, 2007; Klonsky & Muehlenkamp, 2007; Strong, 1998)

14. Myths regarding Self-Injury Myth: Peer pressure is the main culprit for why children and adolescents begin to self-injure Truth: While 52% of teens learn about self-injury from friends or the media, peer pressure has little to do with maintaining it

15. Combating Stereotypes  Stereotypes are grounded in truth, but are ultimately false as they cannot be ascribed to any particular individual  Self-injurious behaviors are overly associated with “emo” or “scene” culture due to the lyrical content of such musical artists and the ascription of self-injury as a fad among “emos”

16. What School Counselors Can Do To Help

17. Your role as a school counselor  When a student discloses self-injury:  Crisis intervention  Self-injury/suicide assessment  Parent notification  Psychoeducation  Linking to resources  Coordinating services

18. What you can do to help  If a student discloses self-injury:  Respond with emotional neutrality – don’t freak out!  Seek medical attention if necessary  Express genuine concern and authentic feelings  Brainstorm other adaptive coping mechanisms  Encourage them to seek mental health services  Be aware of the risk for suicide – but don’t assume their self-injury is indicative of suicidal ideation

19. What you can say to help  My understanding is there are 4 main motivations for self-injury. Do any of these apply to you?  (1) Feeling too much  (2) Feeling too little  (3) Having thoughts of suicide  (4) Wanting to punish yourself  Although self-injury isn’t a suicide attempt, many people struggle with suicidal thoughts. Are you having any thoughts of suicide?

20. Finding a Therapist  Find someone with whom you’re comfortable – an effective therapeutic relationship is essential  Ask questions about their experience working with self- injury (e.g., do they view self-injury as the primary issue or indicative of underlying emotional difficulties)  Learn more about their theoretical orientation – Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) are the most helpful  Group vs. Individual Therapy – find out what your insurance plan will cover

21. Providing Resources Parenting SIB Group Open to clients of Wasatch Mental Health (e.g., traditional Medicaid, school-based behavioral grant, CY-FAST crisis grant) 4-week psychoeducation group focused on understanding self-injury and how parents can assist their children engaging in self-injury

22. Online Resources  Cornell Research Program www.selfinjury.bctr.cornell.edu www.selfinjury.bctr.cornell.edu  To Write Love On Her Arms www.twloha.comwww.twloha.com  S.A.F.E. Alternatives www.selfinjury.com www.selfinjury.com  Secret Shame www.selfharm.netwww.selfharm.net  The Trevor Project www.thetrevorproject.orgwww.thetrevorproject.org  Rape, Abuse, & Incest National Network www.rainn.org www.rainn.org  Suicide Prevention www.suicidepreventionlifeline.org www.suicidepreventionlifeline.org

23. Book Resources  A Bright Red Scream by Marilee Strong  Treating Self-Injury by Barent Walsh  Bodily Harm by Karen Conterio and Wendy Lader  Helping Teens Who Cut By Michael Hollander  Cutting by Steven Levenkron  Bodies Under Siege by Armando Favazza

24. References Conterio, K., Lader, W., & Bloom, J.K. (1998). Bodily harm: The breakthrough healing program for self-injurers. New York, NY: Hyperion. Gratz, K.L. (2003). Risk factors for and functions of deliberate self-harm: An empirical and conceptual review. Clinical Psychology: Science and Practice, 10, 192-205. doi: 10.1093/clipsy/bpg022. Hollander, M. (2008). Helping tends who cut: Understanding and ending self-injury. New York, NY: The Guilford Press. Klonsky, E.D. (2007b). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226-239. doi:10.1016/j.cpr.2006.08.002. Klonsky, E.D., & Moyer, A. (2008). Childhood sexual abuse and non-suicidal self-injury: Meta-analysis. The British Journal of Psychiatry, 192, 166-170. doi: 10.1192/bjp.bp.106.030650. Klonsky, E.D., & Muehlenkamp, J.J. (2007). Self-injury: A research review for the practitioner. Journal of Clinical Psychology, 63, 1045-1056. doi: 10.1002/jclp.20412. Lang, C.M., & Sharma-Patel, K. (2011). The relationship between childhood maltreatment and self-injury: A review of the literature on conceptualization and intervention. Trauma, Violence, & Abuse, 12, 23-37. doi: 10.1177/1524838010386975. Nock, M.K., Teper, R., & Hollander, M. (2007). Psychological treatment of self-injury among adolescents. Journal of Clinical Psychology, 63, 1081-1089. doi: 10.1002/jclp.20415. Polk, E., & Liss, M. (2009). Exploring the motivations behind self-injury. Counselling Psychology Quarterly, 22, 233-241. Spinhoven, P., Slee, N., Garnefski, N., & Arensman, E. (2009). Childhood sexual abuse differentially predicts outcome of cognitive- behavioral therapy for deliberate self-harm. The Journal of Nervous and Mental Disease, 197, 455-457. Strong, M. (1998). A bright red scream: Self-mutilation and the language of pain. New York, NY: Penguin Books.