CUTTING AND OTHER SELF HARMING BEHAVIOR IN ADOLESCENTS

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CUTTING AND OTHER SELF HARMING BEHAVIOR IN
ADOLESCENTS

• PRESENTED BY
• Janice Gabe, LCSW, MAC
• New Perspectives of Indiana, Inc.
• 6314-A Rucker Road
• Indianapolis, IN 46220
• [phone]
• [phone] Facsimile
• www.newperspectives-indy.com
• barb6308_at_earthlink.net

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HOW DO ADOLESCENTS PHYSICALLY SELF HARM?

• Cutting
• Stabbing
• Scratching the skin
• Scraping and rubbing skin, removing top layer
• Placement of sharp objects under the skin or in
  body orifices
• Gnawing at the flesh

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HOW DO ADOLESCENTS PHYSICALLY SELF HARM?

• Biting the inside of the mouth to make sores then
  regularly re-opening them
• Picking at wounds
• Burning skin using heat
• Burning skin by using chemicals or caustic
  liquids
• Pulling hair out, including eyelashes and
  eyebrows

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HOW DO ADOLESCENTS PHYSICALLY SELF HARM?

• Hitting themselves hard enough to bruise self
• Banging head against something
• Tying items around neck, arms, legs to restrict
  blood flow
• Ingesting small amounts of toxic substances,
  enough to get sick but not enough to die
• Ingesting self harming objects such as straight
  pins

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SELF HARMING IS NOT NECESSARILY----

• A suicide attempt
• An indication of early childhood abuse or trauma
• An indication of sexual abuse
• An indication of borderline personality disorder
• A behavior which is limited to females
• A bid for attention

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SELF HARM IS DIFFERENT FROM-----

• Multiple body piercing
• Tattoos
• Branding

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UNDERSTANDING PATTERNS OF SELF HARMING

• WHO DOES IT?
• A. 60 are young women between the ages of 16
  and 25
• B. In this culture it appears to be largely a
  Caucasian female issue
• C. 5 of adult self harmers report
  participating in this behavior in early
  childhood
• D. It is entirely possible that early childhood
  self harm is not reported or recognized
• E. With adults it is always connected to
  significant and early childhood trauma. This
  is not necessarily the case with teens

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• II. WHAT PURPOSE DOES IT SERVE
• A. The primary purpose of self harming is
  to relieve emotional tension
• B. Adolescent girls describe self harming as
  a way to obtain relief from anxiety,
  agitation, anger
• C. Adolescent females often describe self
  harming as the only way to tolerate intense
  feelings without resorting to suicide

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• D. Adolescent females report that
• self harming serves to
• 1. Provide emotional relief
• 2. Alter their mood
• 3. Stop obsessive and troublesome thoughts
• 4. Stops them from behaving in a way that is
  considered bad or unacceptable
• 5. Communicate their anger at others without
  risking conflict or rejection
• 6. Express their anger toward themselves
• 7. Punish themselves for bad things they have
  done or emotions they should not have

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• 8. Stop voices of others in their head
• 9. Stop thinking about trauma (if trauma has
  been present in their past)
• 10. Turn their emotional pain into
  physical pain
• 11. Help them not feel so dead or empty
  inside
• 12. Bring about calming effects
• 13. To let others know that they have
  been hurt and that they have been damaged
  by this hurt
• 14. To obtain care and nurturing to the
  skin and wound (perhaps as a way of
  repairing effects of earlier trauma

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• WHAT ARE MOTIVATIONS
• I. Internal
• About me
• what comes from within me,
• what exists inside of me
• what I think how I feel toward self
• II. External
• about me and others
• about others
• in reaction to
• to get reaction from

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• III. About perceptions
• IV. Communication
• V. Emotions

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• V. WHAT ARE THE PATTERNS OF
• SELF HARM?
• A. Self harm is usually a solitary
  experience. The exception to this are
  teens who are institutionalized
• B. Self harm is often learned from others.
  Teens hear their friends talking about it, or
  see something about it on TV and decide to try
  it
• C. Self harm is often a secret, and is kept
  hidden from adults because the teens are
  ashamed and afraid

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• D. Self harm is usually an ongoing behavior
  once it comes to the attention of adults.
  Single incidents do not usually get detected
• E. Self harm takes on an addictive dimension.
  Teens like the predictable results and find it
  rewarding so they repeat it
• F. Self harm is often progressive in nature,
  they have to do more and more of it in order to
  get the desired result

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• V. WHAT ARE THE BIOLOGICAL RESULTS OF SELF
  HARMING?
• A. Self harming produces the release of
  endogenous opioids. These are
  neurochemicals similar to drugs like heroin.
  They produce a feeling of calm and well-
  being. They are naturally released in the
  brain when a person feels danger or fear,
  or when a person is injured. This will
  enhance a persons ability to survive the
  trauma
• B. Environmental stimuli can trigger a
  trauma reaction and thus, the release of
  opioids

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• C. We can become addicted to our own endogenous
  opioids and need more to be released to
  experience a sense of calm. Self harming is one
  way to get the body to do this
• D. Endogenous opioids are natural pain killers,
  this may be why some girls say they do not feel
  their pain

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• E. When girls stop the self harming, they may
  experience withdrawal from these opioids which
  may increase their agitation and anxiety which in
  turn, triggers urges to continue to self harm
• F. When people are exposed to high levels of
  stress, they experience low levels of serotonin.
  Low levels of serotonin are linked to impulsive
  behavior and lack of constraint. Therefore, this
  makes it easier to indulge in self harming and
  more challenging to stop

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TREATMENT INTERVENTIONS

• I. CREATING THE APPROPRIATE
  ATMOSPHERE
• A. Teens have to be able to talk about it when
  it happens. They wont do this if they
  feel shamed or embarrassed or sense you
  are uncomfortable with them talking about
  it
• B. The role of the professional is to make it
  clear you disapprove of the behavior, but
  not them as a person. They need to know
  that the goal is for them to abstain, but
  this is clearly a therapeutic vs. a
  punitive goal

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• C. How well they respond to therapy depends a
  great deal more on their relationship with the
  helper than any specific therapeutic orientation
• D. The adolescents need to know you will not be
  shocked or overwhelmed by their behavior

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• II. DISCOVERING WHAT IT MEANS TO THEM
• A. One of the first steps in therapy is to
  decide what role or purpose the self harm
  has for this individual adolescent. We have to
  be cautious not to generalize what it usually
  means. Teens feel devalued when we approach
  them this way

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• B. Help the teen recognize her pattern. Talking
  and journaling are excellent tools for helping
  with this. The girls do not see their patterns
  and if we are to help them, they have to be able
  to talk to us. We need to help them answer the
  following questions
• What are the feelings that trigger this?
• Are they feelings about you, about others, about
  your world?
• What are the payoffs and benefits to you?
• What happens in your thoughts before you do this?
• When did you start, how did you learn about it?
• What is your self harm history? (we are looking
  for progression and loss of control)

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• Do others know and how have they responded?
• What do you think about this behavior?
• How do you feel during and after?
• When dont you self harm, whats different about
  these times? What did you do to stop yourself
  and can you use those things again?
• Are there any time patterns to your self harming?
  Do these behaviors occur the same time every
  day, week, month, season, a point in your
  menstrual cycle?

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• Is this a reaction to trauma in your earlier
  life? Does the self harm patterns correlate with
  these past traumas?
• What is your ritual before, during after?
• How do you feel during the behavior do you like
  the pain, do you feel the pain, does it clear
  your head, provide a release, change your mood?

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• C. MOTIVATING CHANGE We Have To Help Them
  Find Some Motivation For Changing
• This Pattern Of Behavior
• How do you feel about yourself after the
  incident?
• How have others reacted to you?
• What have you had to do to cover the scars and
  what has happened when you have been unable to
  cover the scars?
• What image do you have of your life after you are
  free from this?

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• D. CLINICAL INTERVENTIONS Teaching Skills For
  Overcoming Self Harm And Resolving Issues That
  Fuel Self Harming Behavior
• If self harming is triggered by earlier trauma,
  we need to help the client recognize the
  connection between past and present feeling and
  self harming incidents. For many teens, talking
  about all their feelings about the original
  incident and understanding how it has impacted
  them is the extent to their ability to resolve
  trauma directly.

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• Adolescent females need to be taught to identify
  feelings. There is a difference between anger
  and anxiety. We need to help them label and
  explain
• Adolescent females need to identify when their
  self harming is a way to communicate something to
  others. We need to help them identify what
  message they are trying to send, for whom it is
  intended, and a more productive way to get their
  point across

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• Adolescent girls perceive that their feelings are
  unmanageable and they cannot tolerate them. We
  have to encourage them to view this differently,
  particularly since many girls self harm to deal
  with feelings that are a normal part of the
  adolescent process
• Adolescent girls tend to think in terms of all or
  nothing. They think in order to deal with
  unpleasant feelings, they have to be extinguished
  entirely. In reality, they have to lower their
  stress just enough to get it into the range of
  tolerable

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• A significant portion of the work we must do with
  adolescent females involves changing scripts that
  do not serve them well. Examples of scripts and
  changes that have to occur with scripts include
• I cannot stand it when someone is mad at me.
• BECOMES
• I can survive someone being mad at me.
• I am so bad I deserve to be punished.
• BECOMES
• I am not perfect but I do not deserve to be
  punished.

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• I cannot handle my terrible feelings.
• BECOMES
• My feelings are painful, but they will not
  last forever.
• I am not good enough.
• BECOMES
• I am good enough.
• I am not lovable.
• BECOMES
• I am lovable.

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• E. TEACHING BEHAVIORAL SKILLS TO DISRUPT THE
  CYCLE
• Clear out objects that are instruments of self
  harm.
• Develop a plan for sharing feelings when they
  occur. This includes recognizing the start of a
  cycle and talking to someone before the feelings
  escalate if possible.
• Teach distraction techniques finding an activity
  that is incompatible with self harming, leave the
  danger zone where self harming usually occurs,
  engage the body and mind in an activity.

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• BEHAVIORAL SKILLS CONTINUED
• Teach teens how to clear their heads and distract
  their thoughts bumble bee breath, count
  backwards from twenty, say the alphabet backwards
• Teach self soothing skills. Teach relaxation,
  anxiety reduction breath, calming rituals,
  moonbeams, music
• Teach them to break things down into manageable
  components (I just have to deal with the next
  five minutes)

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• BEHAVIOR SKILLS CONTINUED
• Teach alternative discharge of hand energy (worry
  stones, koosh balls)
• Recognizing triggers. Classify triggers into two
  categories ones that can be avoided (avoid
  these), ones that cant be avoided (come up with
  a plan to deal with these)

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• F. CONSIDER REFERRAL FOR MEDICATION
• Antidepressants
• Mood stabilizers
• Anti-anxiety medication

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• G. WORK ON BOUNDARY ISSUES
• Self Over Others
• Others Over Self
• External
• Internal

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• Parents As Part of The Solution
• Assist them understanding and processing
• own reaction
• Understanding what it means for their child
  and childs triggers
• Discuss appropriate
• - responses
• - monitoring
• - limits
• - consequences
• - communication
• Develop plan for support