SelfMutilation: Response of the School Psychologist

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Self-Mutilation Response of the School
Psychologist

• Melissa Pearrow, Ph.D.
• University of Massachusetts - Boston

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Gruesome Discussion Alert!!

• If you have ever worked with individuals who
  self-harm, you are aware that the discussions can
  become very graphic
• Acknowledge the difficulty in discussing this
  topic because impacts many people and respect is
  required with this discussion
• Important to become aware of our own reactions to
  this behavior for the sake of those struggling
  with it
• This work is not easy!

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Why?

• I hurt myself today to see if I still feel. I
  focus on the pain. The only thing thats real.
  - Trent Reznor NIN
• Generally, individuals who engage in deliberate
  self-harm (DSH) are in a lot of emotional pain
  and they do not have healthy methods for coping
  to manage this pain.

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Statistics

• School staff can become frustrated if send these
  students to an emergency room
• Ratio females three times as likely as males
• Prevalence rates in community sample
• 12-13 engaged in DSH in past
• 5-6 engaged in DSH in the past year
• Only 12.6 were seen by medical providers

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Statistics

• Prevalence rates in inpatient population
• 30-60 had history of DSH, average onset age 13
• Over half had DSH more than 19 times in last year
• 56 problem with alcohol 30 used street drugs
  61 admitted having had an eating disorder
• Attention-seeking or manipulation cited as reason
  for DSH less than 15 of the time

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Cultural Components

• Studies conducted in Western culture England,
  Australia, and United States
• Sociologists propose a continuum of DSH from
  acceptable (e.g., tattooing and piercing) to
  upsetting to mainstream
• Differentiated by intent and purpose
• Cultural sanctioned practices may not translate
  to other cultures
• Comparative discussions

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Definition of Self-Harm

• Self-mutilation Intentional, non-life
  threatening, self-effected bodily harm or
  disfigurement of a socially unacceptable nature,
  performed while in a state of distress

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Three Categories of Self-Harm (Favazza, 1998)

• Major self-mutilation - involves a great deal
  of tissue damage, such as eye enucleation or
  castration, and is commonly associated with
  psychosis
• Stereotypic harm - includes behaviors such as
  head banging and is associated with organic
  disorders such as mental retardation
• Superficial/moderate - most frequently observed
  type of self-mutilation, is and most frequently
  includes skin cutting or burning

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Indirect Self-Harm

• Substance abuse alcohol, marijuana, cocaine,
  inhalants, ecstasy, IV drugs
• Eating disorder fasting, self-induced vomiting,
  use of laxatives, obesity
• Physical risk taking walking on a high pitched
  roof or in traffic
• High risk sexual behavior unprotected with
  multiple partners, sex with strangers
• Unauthorized discontinuation of psychotropic
  medication

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Separating Suicide Self-Harm

• Self-injury is usually a life-sustaining act
• To cope with stress
• Impulsive thought about for less than an hour
• Relieve inexpressible feelings
• Gain attention
• Life preserver rather than exit strategy
• May get angry if called suicidal
• Suicidal behavior - The human act of
  self-inflicted, self-intentioned cessation
• Suffer from very long-term and profound
  depression
• Sustained feelings of hopelessness

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Initial Assessment

• If modesty allows, ask to see the injury, include
  the school nurse if necessary
• Why was that body part chosen?
• Is it the typical body part chosen?
• How frequently does behavior occur?
• Was this the typically used instrument? What
  instruments are used?
• How many times hurt self in this self-injurious
  event?

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Assessment (continued)

• Where do they perform the self-injury (location)?
• When do they typically self-injure?
• Are they alone when they self-injure?
• If not, does someone else perform the mutilation?
• What purpose does the action serve?
• What triggers the event?
• Do others know that they self-injure?

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Case Studies

• 15 year old female
• substance abuse
• eating disorder
• significant parenting issues
• duties and liabilities
• response of parents

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Dialectal Behavior Therapy (Linehan, 1993)

• Behavioral treatment to reduce self-harming
  behaviors of client diagnosed with Borderline
  Personality Disorder
• Explains BPD primarily as a disorder of the
  emotion regulation system
• A modified cognitive-behavioral treatment founded
  on a biosocial theory
• Gives structure to treatment providers who can
  easily feel overwhelmed and inadequate

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Is DBT important to school staff?

• Self-harming behaviors are being seen more
  frequently by school staff
• Empirically supported treatment for deliberate
  self-harm in multiple settings
• Treatment has been applied to adolescent
  inpatient, residential, and outpatient settings

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Is DBT important to school staff?

• DBT has its own language with acronyms for
  skills learned
• Application of behavioral constructs can assist
  with educational planning - after a student has
  hurt themselves, they have already coped
• School mental health staff as coaches to help
  the adolescents use newly developed coping skills

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Biosocial Theory of DBT

• Biological vulnerability to emotions
• Invalidating environment (leading to
  self-invalidation)
• Behavior problems confusion about self,
  impulsivity, emotional instability, and
  interpersonal problems

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Components of DBT

• Dialectical worldview - Primary principles
• Interrelatedness and wholeness
• Polarity
• Continuous change
• Cognitive behavioral therapy
• Techniques of thought diary, behavioral analyses,
  contingency management, and shaping

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Dialectic Dilemmas of Adolescence

• Fostering dependence versus Fostering
  Independence
• Excessive leniency versus Authoritarian control
• Normalizing pathological behaviors versus
  pathologizing normal behaviors
• Accepting them as they are while also trying to
  help them change

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A Few Assumptions of DBT

• Clients are doing the best they can
• Clients want to improve
• Clients need to do better, try harder, or be more
  motivated to change
• Clients may not have cause all their own problems
  but they have to solve them anyway
• Clients lives are unbearable as currently lived

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Structure of DBT

• Treatment and training are intensive - Requires
  two full weeks of training to be certified as DBT
  therapist
• Outpatient individual psychotherapy diary
  cards, behavioral analysis, hierarchical goals
• Outpatient group skills training
• Telephone consultation
• Therapists consultation meeting
• Adult model 1 year commitment
• Adolescent model 12-20 week commitment

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Adolescent Group Skills Training

• Skills training is didactic and structured
• Homework is assigned at each group
• Adolescent treatment varies from adult treatment
  by involvement of the family
• Adolescents engage in treatment with a coach
  with goal of generalizing skills to natural
  environment
• Teaches validation skills to coaches

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Skills training focuses on

• General goal To learn to refine skills in
  changing behavioral, emotional, and thinking
  patterns associated with problems in living, that
  is, those causing misery and distress
• Specific goals
• Emotion regulation skills
• Interpersonal effectiveness skills
• Distress tolerance skills
• Core mindfulness skills

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Core Mindfulness Skills

• First skill learned and highlighted throughout
  treatment
• Consists of observing, describing, and
  participating in ones environment
• Adopts a nonjudgmental stance
• Presents three state of mind

Reasonable Mind
Wise Emotional Mind Mind

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Emotional Regulation

• Teaches skills to
• Understand and identify emotions
• Reduce emotional vulnerability
• Decrease emotional suffering
• Act opposite to emotion
• Build positive experiences

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Emotion Regulation

• P treat physical illness
• L like yourself
• E balance eating
• A avoid mood-altering drugs
• S balance sleep
• E get exercise
• MASTER build mastery

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Distress Tolerance

• Crisis survival skills - Get through a crisis
  without doing something to make it worse
• Distract ACCEPTS Activities, Contributing,
  Comparisons, Emotions, Pushing away, Thoughts,
  and Sensations
• Improve the moment
• Self-soothe use the five senses
• Pros and Cons list out short and long term
  consequences of coping or not coping
• Radical Acceptance

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Interpersonal Effectiveness

• Teaches skills to
• Get own objective or goal into situation
  DEARMAN Describe, Express, Assert, Reward, (take
  hold of your) Mind, Appear confident, and
  Negotiate
• Keep a good relationship GIVE be Gentle, act
  Interested, Validate, and use an Easy manner
• Keep your self-respect FAST be Fair, no
  Apologies, Stick to values, and be Truthful

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Why validate?

• Skills taught to coaches but can also teach
  these skills to school staff and parents
• Leads to trust
• Improves communication
• Strengthens certain behaviors
• Good for people helps them feel valued, secure,
  cared for, important
• Good for relationships
• Improves ability to cope effectively

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Validation

• It communicates understanding by
• Acknowledgement observe, describe,
• non-judgmentally
• Communication
• Acceptance
• Legitimizing
• It is NOT
• Necessarily agreement
• Mean that you like it

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How to Validate

• Attentive listening
• Reflect the others feelings
• Summarize the others perspective, descriptively
• Show tolerance meaning give the benefit of the
  doubt
• Be mindful of the importance of the relationship
• Take the other person seriously
• Provide nurturance and support

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Teaching the Person What to Validate

• Themselves, others, relationships the value of
  relationships with others and with their self
• Thoughts, feelings, intentions, goals, desires
  recognize feelings, worries and fears as
  feelings, worries and fears, not as facts
• Effective behaviors
• Facts
• Their value as a person