Working with Selfinjurious Youth in Schools

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Working with Self-injurious Youth in Schools

• ISPA Colloquium, July 2007
• Tampere, Finland
• Dr. Steve Hoff
• The College of Saint Rose
• sehoff_at_adelphia.net

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Alice Miller
The truth about childhood is stored up in our
body and lives in the depth of our soul. Our
intellect can be deceived, our feelings can be
numbed and manipulated, our perception shamed and
confused, our bodies tricked with medication.
But our soul never forgets, and because we are
one, one whole soul in one body, someday our body
will present its bill.
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Definitions

• The direct, deliberate destruction or alteration
  of ones own body tissue without conscious
  suicidal intent
• Favazza (1987)
• Self-mutilative behavior is deliberate,
  non-life-threatening, self-effected bodily harm
  or disfigurement of a socially unacceptable
  nature
• Walsh Rosen (1988)

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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)

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Cultural ContextBody piercing, marking and
modification in tribal cultures

• Rite of passage
• Lifelong peer bonding
• Sign of respect for elders
• Status belonging, bravery, beauty
• Protection from evil spirits
• Connection to spirits/energies

Fakir Musafar, father of The Modern Primitive
Movement
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Pathology

• Major SM includes infrequent acts such as eye
  enucleation and castration, commonly associated
  with psychosis and intoxication.
• Stereotypic SM includes such acts as head banging
  and self-biting most often accompanying
  Tourette's syndrome and severe mental
  retardation.
• Superficial/moderate SM includes compulsive acts
  such as trichotillomania and skin picking and
  such episodic acts as skin-cutting and burning
• Favazza (1998)

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Knife Inflicted Wounds
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Eraser Burns
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Plastic CD Cover Carving
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Cigarette Burns
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Cross-cultural Considerations

• Cross-cultural references in literature, but not
  a lot of hard data
• Self-harm among Asian women in UK
• Journal of Community Applied Social Psychology
  (1999)
• Self-harm as release from distress, effecting
  change, taking control
• Feminist perspective on self-injury (US)
• Feminism Psychology (2002)
• Cutting reflects developmental struggles within
  patriarchal culture
• Contagion in a closed psychiatric unit Turku
  University Central Hospital in Southwestern
  Finland
• Journal of the American Academy of Child
  Adolescent Psychiatry (1998)
• Contagion is a serious concern and can spread to
  previously non-cutters

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BronfenbrennerEcological Systems Theory

• MUST consider child in context
• CHILD
• Classroom/Peers/Teachers
• Community/Homelife
• Society/Media
• Time/Change

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Profile

• Depressed
• Anxious
• Sexual abuse survivor
• Eating disorder
• Borderline personality traits
• Adolescent female

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Emotional State
Internet survey of adolescent self-injurers.
Murray, Warm and Fox Australian e-Journal for
the Advancement of Mental Health (2005) n128

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Neurobiology

• The body keeps the score - Judith Herman, MD
• Body memories. Requires frontal lobe processing
  to combat what has been embedded in our being
• Kindling theory of changes in brain structure
• Robert Post, MD Chief, Biological Psychiatry
  Branch, National Institutes of Mental Health
• Constant release of adrenaline, emotional
  memories
• EMDR
• Body Therapies Yoga, Danckinetics
• SSRIs or anti-anxiety medication to treat
  underlying depression and stop impulsive acts

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School Specific Recommendations

• Offer care and non-judgmental support to the
  student
• Refer student to community clinical services
  coordinate with parent
• Involve the crisis team and all appropriate
  personnel (nurse, etc.)
• Consider suicide risk
• Train staff to recognize signs of self-injurers
  and to inform
• Limit contagion by keeping a low-key individual
  focus. Dont glamorize or over-dramatize
• Richard Lieberman LA Unified School District
  Suicide Prevention Unit, Co-Chair of NASPs
  National Emergency Assistance Team (2004)

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School Recommendations continued

• Groups
• Problem solving
• Self-esteem building
• Stress management
• Social skills training/building peer
  relationships
• Activities
• Sports
• The Arts
• Individual
• Supportive counseling
• NOT direct and intense individual work around
  cutting due to contagion risk and lack of
  structured clinical environment

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TREATMENT CONSIDERATIONSDos!

• Think strengths
• Get her 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
  whats behind it
• Talk about alternatives to cutting

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TREATMENT CONSIDERATIONSDon'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

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TreatmentAttachment and Corrective Emotional
Experience

• History of conflict in relationships
• Difficulty having healthy connections
• Few, if any, positive relationships with adults
• Relationship with therapist can change the
  clients perception of what relationships CAN BE
• Franz Alexander

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• DBT
• Try to change AND try to Radically accept
• Mindfulness
• Distress Tolerance
• Emotion Regulation
• Interpersonal Effectiveness

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There are 2 ways to wash the dishes. The first
is to wash the dishes in order to have clean
dishes and the second is to wash the dishes to
wash the dishes Thich Nhat Hanh The
Miracle of Mindfulness
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Jen and the Cardinal
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Suicide Risk
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Suicide Risk AssessmentMental Status

• Intensity and focus of ideation
• Evidence of planning and especially behavior
• Current stressors
• Social isolation
• Depressive symptoms assess degree of
  hopelessness
• Thought disorder symptoms
• Substance abuse
• Suddenly brightened mood
• Access to Lethal Means
• Robert Kinscherff, Ph.D., J.D. South Boston
• Family Court, (2004)

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Suicide Risk AssessmentKey Factors

• Mood disorder, anxiety disorder, substance abuse
• History of physical or sexual abuse
• GLBT youth
• History of past suicide gesture or attempt for
  self or close relative
• Recent suicide of peer contagion risk
• Robert Kinscherff, Ph.D., J.D. South Boston
• Family Court, (2004)

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Suicide Risk AssessmentProtective 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)

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Recommended Reading

• Ashworth, A. (1998). Once in a house on fire.
  New York Henry Holt and
• Company.
• Favazza, A.R. (1987). Bodies under siege
  self-mutilation and body modification in culture
  and psychiatry. The Johns Hopkins University
  Press.
• Herman, J. (1992). Trauma and recovery. New
  York Basic Books.
• Levenkron, S. (1999). Cutting Understanding and
  overcoming self-mutilation. New York Norton
  and Company, Ltd.
• Miller, D. (1994). Women who hurt themselves.
  New York Basic Books.
• Myers, B. (1980). Incest If you think the word
  is ugly take a look at its effects.
• In Sexual abuse of children selected
  reading/National Center on Child Abuse and
  Neglect/Administration for Children Youth and
  Families/Office of Human Development
  Services/U.S. Department of Health and Human
  Services.
• Salter, A.C. (1995). Transforming trauma.
  California Sage Publications.
• Strong, M. (1998). A bright red scream. New
  York Penguin Books.
• Terr, L. (1994). Unchained memories. New York
  Basic Books.
• van der Kolk, B.A., McFarlane, A.C. and Weisaeth,
  L. (Ed.) (1996). Traumatic stress. New York
  Guilford Press.
• Walsh, B. and Rosen, P. (1988).
  Self-mutilation Theory, research and treatment.
  New York Guilford Press

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Self-inflicted Mud Pie
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