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Responding to Self-harm in Schools Dr Erin Bowe Clinical Psychologist Welfare Guardian

 Current and preferred term is ‘nonsuicidal self-injury’ (NSSI)  ‘self-harm’ or ‘self-injury’ is easier for everyday speak  Regional differences in terms  Self-poisoning has different motivations & lethality Nomenclature

 To better equip yourself and staff to deal with common incidents  To improve skills in determining appropriate level of response for a range of possible crisis events  To learn tricks in using principles of calm, factual and non- emotive language  To have a clearer understanding of how to seek further advice and support for yourself, staff, students and parents Introduction: Goals of session

 Understanding self-harm behaviours  Responding to crisis  Communication skills  Special considerations within school settings  Self-care, supervision and referral Overview

Pre and post-workshop reflection 0= NOT AT ALL CONFIDENT 1= SOMEWHAT CONFIDENT2= CONFIDENT How confident do you feel:  Working with students who have engaged in self-harm?  Being able to differentiate a crisis from more intermediate and mild incidents?  Understanding best-practice treatment approaches for self-harm?  That you could handle a crisis?

 Deliberate cutting, burning, scratching with the intent of causing bodily tissue  For the purpose of affect regulation (to feel ‘better’, ‘calmer’ or just ‘different’)  Almost always non-suicidal  Usually repetitious  Usually associated with powerful, rewarding psychophysiological responses  A maladaptive, but effective coping strategy Self-harm is

 A suicide attempt  Parasuicide (behaviour which mimics suicide attempt)  (Sub)culturally accepted body modification  Stereotypic/compulsive self-harm (neurological basis)  Psychotic self-harm (e.g., self-amputations)  Indirect or cumulative bodily damage (eating disorder, substance use, or risky stunts) Self-harm in this context is not to be confused with:

Predisposing factors Stressful eventsSelf-harm specific factors Self-harm outcome =+x Cognitive-emotional- biological vulnerability High emotion reactivity Emotional numbing Poor distress tolerance Thought suppression Rumination Social vulnerability Early abuse/maltreatment Familial hostility/criticism Poor communication skills Poor problem solving Stressful event Triggers over or under Arousal (automatic Functions) OR Event presents high Social demands (Social function) Self-harm High self- criticism Modelling of peers/media Need for strong/honest signal Regulation of emotional experience Regulation of social situation Psychological model of the development and maintenance of self-harm (Nock & Cha, 2009)

 Appears to be 3 possible pathways 1.‘One-off’, non-rewarding response (about 30%) 2.Tension reduction* response (about 70% will repeat) 3.Atypical, excitation** response (seen in Borderline PD; or a least a subtype of BPD, unknown % but likely very low) *Well established in literature **Less well established in literature, still speculative Who does it?

Increased levels of negative emotions Depersonalisation occurs Individual reaches a level they are no longer able to tolerate Engage in act of self-harm with little/no pain (injury opens access to the brain’s 24 hour pharmacy of endorphins & opiates) Repersonalisation occurs (negative reinforcing property) ‘Typical’ response: tension reduction model

 Poor coping skills  Low tolerance for negative emotions  Impulsive, want instant relief  Perceived lack of control  High levels of dissociation  Often unable to utilise problem solving once distress reaches a certain threshold Typical response

 Experience interpersonal conflict, rejection, separation, anger, self-hatred, depression, loneliness and abandonment  Experiences may be real or imagined  As self-harm become habitual, cutting is often precipitated by more minor events Typical response

 Most people have a hard time explaining “why” they cut (content)  But can describe what, where, how led to the behaviour (process)  Does the “why?” change anything?  Fundamentally, self-harm is a maladaptive coping strategy  It’s an attempt to communicate distress  Counsellors should try to prioritize process over content Faulty Assumptions- “why?”

 You or another student finds someone cutting in private (e.g., in bathroom) 1.Respond neutrally & model calm posture (think: relax jaw, relax hands, relax shoulders) 2.Offer support (get band aids, offer a chance to talk about it) without being reactive 3.Use empathic statements, focus on immediacy Crisis #1

4. Immediacy- ask the student what s/he wants to happen next an offer 2-3 options. 5. Follow up. Book a time to talk, or talk to the student about referral. 6. Reflect on your own self-care & debriefing needs Crisis #1 continued

 A student or students engage in self-harm in front of others (e.g., in class) 1.Use empathic reminders that (1) it’s ok to be upset, but (2) others are upset by the behaviour. 2.Offer support (bandaids, a chat) 3.Offer 2-3 options: 1. clean up & go back to class, 2. Sit somewhere quiet with a friend until next class, or 3. visit counsellor/debrief with someone Crisis #2

4. Manage any other students’ distress by acknowledging & validating, but quickly moving forward (give the same options – break, talk, or resume class) 5. Follow up. Book a time to talk, or talk to the student about referral. 6. Reflect on your own self-care & debriefing needs. Crisis #2 continued

 A student reveals that s/he has engaged in self- harm (but no current crisis) 1.Simply ask the student what s/he wants to have happen now (talk now, or later?) 2.Make sure a follow up time is booked (preferably by the end of the day) 3.Aim to clarify the intent (“so the cutting was about feeling overwhelmed, but not about taking your life?”) Non-immediate crisis

4. Encourage parental communication (consider age and mature minor principle if necessary) 5. Encourage a referral to an external psychologist (particularly important if the student is not open to parental disclosure) Non-immediate crisis cont.

 No, not unless absolutely necessary  Tends to reinforce the behaviour  Increases feelings of rejection & isolation Send students home?

 Represents a unique but not unusual occurrence in ‘institutional’ settings (schools, hospitals, prisons)  Contagion effect  Important to correct any misinformation and address ‘us vs. them’ phenomena  Work towards strengthening alliance between parents, adolescents and counsellor Self-harm in groups & cliques

 Can be effective if student has a circle of non self- harming friends  Similarly, older students who have recovered are a strong source of modelling and support  Groups with only people who self-harm need to be selected very carefully, they need to be highly structured and run by an experienced therapist Addressing the Issue: Groups?

 False assumption that all members want to change; or that the motivation for change is stable/consistent  Participant matching issues in school setting  Members can often provide false validation rather than support  Extra challenges with personality disorder, trauma, eating disorder and substance use  Risk of re-triggering & re-traumatisation  Risk of ‘one-upmanship’ behaviours  Biased motivations for participating  ‘sharing’ not as effective as structured skill-based groups Risks with Groups

 Immediacy  Neutral tone of voice, face and statements  Importance of orienting the student to counselling process  Try to avoid the temptation to get into lengthy discussions with students or parents about “why” people self-harm  Teach/model skills in emotion identification, labelling and explaining  Focus on the factual information about the mechanics or the process (i.e., reduces heart rate, body releases natural feel-good opioid hormones) Communication skills

 Crisis management, putting out ‘spot fires’  Educating others, translating knowledge  Explain behaviour curve- delay, distract, decide  Ongoing motivational interviewing  Encourage replacement skills early on, but acknowledge their limited use & use as a tool for encouraging long-term strategies Realistic options for school counselling

 Anxiety is the biggest block to care  Listening your own thoughts, rather than the students  Can’t be present and calm if you’re rehearsing  Questioning like a lawyer rather than an anthropologist  When you’re working harder than the client  Being impatient or intolerant of silence  Mismatching your approach to client’s actual stage of readiness to change Road blocks to student care

 If ever in doubt, refer out  Most self-harm takes 12 mo+ to treat effectively  Emphasise confidentiality  Validate ambivalence about seeking help & keep encouraging  Achievable goal in short-term for most students is (1) waiting skills and (2) reducing frequency (rather than cessation) Referring out

 Responding to Crisis flowchart  Basic Distraction Techniques  Handout for Parents  Quick Facts about self-harm  Tips and strategies for adolescents  Tips and strategies for younger children Worksheets and Handouts

 Self-harm is almost always non-suicidal  Maladaptive but effective coping strategy  Is a way of communicating distress  The psychophysiology of self-harm is very powerful  Is incredibly difficult to treat. Follows similar patterns to other addictive behaviours  Addressing motivation to change is crucial first step  It must be the individual’s choice to stop, you cannot make someone stop Summary

 Familiarise self with facts, practice neutral communication  Differentiate immediate crisis from more mild or intermediate events  Consider how to make transition from self-harm incident back to regular activities more seamless  Consider how to tackle cliques (talk to each member one on one to reduce contagion)  Remember to reflect and address own self-care Summary

0= NOT AT ALL CONFIDENT 1= SOMEWHAT CONFIDENT2= CONFIDENT How confident do you feel:  Working with students who have engaged in self-harm?  Being able to differentiate a crisis from more intermediate and mild incidents?  Understanding best-practice treatment approaches for self-harm?  That you could handle a crisis? Post-workshop reflection

 This time of year is usually the beginning of ‘peak’ self-harm trends in schools  Do you need further support, coaching or guidance about how to manage self-harm in schools?  Just need someone external to school to bounce ideas off?  Individual supervision via Skype or at our Port Melbourne office is available Supervision