Cutting it Fine: SelfInjury in C ntext

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Cutting it FineSelf-Injury in C ntext

• Professor Graham Martin
• OAM, MD, FRANZCP, DPM
• g.martin_at_uq.edu.au

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John

• Oh! Do it again Doc!

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Body Art

• The Australian Museum
• Exhibition 2000
• http//www.austmus.gov.au/bodyart/about/index.htm

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Tribal Connectedness and Representation
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Ancient Tattoos

• Tattooed markings on skin and incised markings in
  clay provide some of the earliest evidence that
  humans have long practised a wide range of body
  art.

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Ötzi the Ice man

• This frozen human was found in the Austrian Alps
  and dates to 5,300 years ago. His is the oldest
  tattooed body known.

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Tattooing in Japan (Jômon period)

• Earliest evidence of tattooing in Japan (3000
  years ago) comes from figurines called dogu,
  which display similar markings to the tattooed
  mouths of the Indigenous of Japan (Ainu).

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Samoan Tattooing

• The word tatau (tattoo) in Samoan means
  appropriate, balanced and fitting.
• The order in which the tattoo is applied is
  always the same. The lumbar region (where the
  Samoan mythical figures Taema and Tilafaiga were
  joined) is always tattooed first and the navel
  last. The navel design is very important and is
  called the pute. Without this, the tattoo is
  unfinished and the wearer carries a sense of
  shame because he was not able to complete the
  ceremony.

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Maori Culture

• Ta Moko is like a history of a person's
  achievements and represents their status in their
  tribe. The left side of the face relates to the
  father's history and the right side to the
  mother's history.
• Originally, Ta Moko was chiselled into the skin
  using an albatross bone.

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Papuan Scarification

• In Papua New Guinea, scarification is related to
  initiation. The Wagan ceremony celebrates the
  return of the ancestral crocodile. The skin on
  the chest, back and buttocks of the initiate is
  cut with a bamboo sliver to test a young mans
  physical strength and self-discipline.

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Papuan Scarification

• The marks have many meanings for me. I wear
  the marks of
  the ancestral crocodile. This is a power mark, a
  spirit, a security used for protection and
  connection with the totems and ancestors of my
  clan, the 'Crocodile Men of East Sepik', Yenchen
  Village, Papua New Guinea
• Ben
  Lewis,
• Healer
  and Performer, 22

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Aboriginal Scarification

• In Australia, scarring was practised widely, but
  is now restricted almost entirely to parts of
• Arnhem Land.
• We call them bolitj(adornment scar) Bob
  Burruwal,
• Rembarrnga, Arnhem Land

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Aboriginal Scarification

• Each deliberately placed scar tells a story of
  pain, endurance, identity, status, beauty,
  courage, sorrow or grief.
• You must have the cuts before you can trade
  anything, before you can get married, before you
  can sing ceremonial songs.

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Tattoo Togetherness

• Janet's tattoos on her arm include a Ganesha -
  a Hindu deity who has the power to remove
  obstacles.
• Tattoo artist Mike states that the imagery on his
  body is "his soul on the outside."

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Contemporarybranding cutting

• My body adornments are about my inner spirit,
  love, trust, truth, strength and beauty, which in
  turn makes up my outward spirit, enabling me to
  be the strong, brave, loving woman I am
• Pauline

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Body Scars

• Tribal Belonging
• Rite of Passage
• Myth
• Art
• Memories of Failure and Success

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The size of the problem

• Estimated 2 million people in the US use
  self-injury to deal with intolerable inner
  feelings of pain, stress, anxiety, depression
  despair
• Keith Hawton et al (JAACAP, 2002) suggest that
  3.6 school based adolescents (ages 15/16) have
  self cut.
• Irish National Suicide Research Foundation (2004)
  found a lifetime prevalence of 5.7 overall with
  9.1 female and 2.4 male.
• 6.2 of secondary school students over previous
  year (De Leo Heller, 2004)

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AUSTRALIA - EDED Study(1st year High School -
aged 13)

• Deliberate Self-Injury - 273 (14.3)

F M All
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EDED study - logistic regression

• Classic correlates of depression and sexual abuse
  - not significant
• Surprise finding of physical abuse and anxiety as
  major predictors
• Only suicide attempt predicted the multiple
  episodes

Martin G., Bergen,H., Roeger, L. Allison, S.,
2006. Correlates of non-suicidal self-harming
behaviour in young community adolescents.
Submitted
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Extended Adolescence

• Weve lost our ability to help young people enjoy
  life in reasonable ways
• Weve lost our connectedness as a society
• Weve lost our rituals to provide a Rite of
  Passage to Adulthood
• Life and Death play of young people may replace
  lost ritual (Rob Barrett, Adelaide)

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Belly Ring

• Has gained acceptance in our society

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Eyebrow Body Art

• Also accepted

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Tongue Studs

• Perhaps less accepted or acceptable

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Ear Piercing

• One or two?

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Ear piercing

• Or more?

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Facial Piercing

• Over the top?

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Lips and Noses

• A little harder to take perhaps

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Nipples and Genitals

• For most of us, probably way over the top

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Artificial Scar

• Now we are getting problematic

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Piercing Ritual

• Hanging about
• A Club I definitely do not want to join

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The Body Sacred
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Whirling Dervish
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Voodoo Ritual

• Animals are sacrificed
• People may or may not get injured
• Through the Ritual
• Through Ecstacy
• Through Belief

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Hindu Sadhu or Fakirs

• Walking on Hot Coals has become common as a
  management development test.
• Penetration of the Skin has (as far as I know) not

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Self Injury as a Continuum

• From the Body as Sacred (the need to put out
  devils)
• Through the body as expression of uniqueness or a
  symbol of joining
• To the Body as Instrument of Pain and Bleeding to
  relieve our inner suffering

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Spiritual Intelligence (Zohar)

• Ecstasy and the God Spot
• Hypothalamus contains a small group of cells
  which resonate at 40 Hz during visions, psychotic
  experience, ecstasy, religious experience and
  with certain drugs
• Michael Jackson (quoted in Zohar) chapter Benign
  Schizotypy? The case of spiritual experience in
  Claridge, G Schizotypy Oxford University Press,
  Oxford, 1997

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SEROTONIN IN CUTTING

• Low levels of 5-HIAA in CSF of depressed suicide
  attempters (Asberg et al., 1976)
• Reduced levels of 5-HIAA in male borderlines
  (Brown et al., 1982)
• Low serotonin correlated with suicide attempts,
  assaultiveness, instability, aggression
  impulsiveness (Coccaro et al., 1989 Markowitz et
  al., 1995)
• Self-mutilators have more personality pathology,
  greater lifetime aggression, more antisocial
  behaviour, and lower levels of serotonin activity
  (Simeon et al., 1992)

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The Inner Pain

• Jenni (14) electively mute after she was raped.
• She repeatedly harmed herself in small ways but
  for 4 months could not verbalise either her
  feelings or what had occurred.

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Kelly
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More Serious Typesof Self Injury

• Stomach Cutting

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More Serious Typesof Self Injury

• Techno
• and Star

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More Serious Typesof Self Injury

• Chest cutting

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More Serious Typesof Self Injury

• Biohazard
• and
• Skull

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Religious Fervour ?

• Jesus
• And
• Mandala

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Parts of Body Injured (Murray et al 2005)
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Psychology of self-injury

• Feldman, 1988
• Van Der Kolk, 1989
• Favazza, 1989
• Linehan, 1993
• Allen, 1995
• Suyemoto, 1998
• Levenkron, 1998
• Osuch, Noll Putnam, 1999
• Hawton Van Heeringen, 2000
• Gratz, 2000
• Humband Tantaim, 2004

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STEPS TO EFFECTIVE PRACTICE WITH SELF-INJURY IN
YOUNG PEOPLE
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Self Injury Motivation ScaleOsuch EA, Noll JG,
Putnam, F.W. (2000). The motivations for
self-injury in psychiatric inpatients.
Psychiatry 62334-346.
Current SIMS study on inpatient adolescents
(Martin et al.)

• To show others how hurt I feel
• To distract myself from emotional pain
• To punish myself for being bad
• To decrease an empty feeling
• To produce a feeling of numbness
• To keep bad memories away
• To reduce a feeling of being utterly alone
• To experience a high like a drug high

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Moving on from Self-Harm (MOSH - Martin et al.,
2006)
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Moving on from Self-Harm (MOSH - Martin et al.,
2006)
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Mental Health in Schools (WHO)
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If Then

• If you are anxious about helping with the crisis,
  managing the process, or doing the therapy, then
  trust your own feelings
• Seek alternative care for the young person
• OR
• Alternatively seek regular supervision to enable
  you to cope with confidence

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If Then

• If the self injury needs medical attention then
  seek appropriate help.
• Ensure the young person is not treated badly,
  roughly or with disdain by medical or other
  staff. Explain, if you have to, that at this time
  this is the only way they can seek help

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If Then

• If a professional complains that the young person
  is attention seeking, then gently and
  respectfully explain that is exactly what they
  need - attention.
• It is just that, at this time, we have not been
  able to help them share their inner pain

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CRISIS INTERVENTION

• Listening and Responding
• Define the Problem
• Ensure Safety (Client, Family your own)
• Provide Support
• Acting and Involvement
• Examine Alternatives
• Make Plans
• Gain Commitment

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CRISIS INTERVENTION

• Never be sworn to secrecy
• Up front, make it clear that what is said may be
  confidential, but you have the right to make your
  opinion public - particularly if you think the
  young persons life (or someone elses) is in
  danger

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CRISIS INTERVENTION

• Do not focus, at this time, on the self injury
  more than you have to in ensuring safety
• Focus on developing a supportive relationship, a
  clear plan for ongoing care, and/or a therapeutic
  alliance
• A relationship
• A set of clear tasks
• Toward a clear goal (short and/or long-term)

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Tension Reduction

• Cutting is not about Suicide
• Cutting is an effective method of tension
  reduction in troubled young people
• Replace self-injury with other less destructive
  behaviours that achieve the same outcome

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Distraction TechniquesAmerican Academy of Child
Adolescent Psychiatry

• Counting to 10
• Waiting for 15 mins
• Thought stopping
• Breathing Exercises
• Journaling
• Drawing
• Thinking about Positive Images
• Using Ice
• Using Rubber Bands

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If Then

• If you feel the young person is (for instance)
  depressed then try to get some simple measure of
  this
• Trust the young persons responses
• Use a Visual Analogue Scale (0-10)

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If Then

• If the scale score is 7 or over out of 10 then
  try to find out whether life is worth living
• If the answer is no, then check for any reasons
  the young person may have for living (future,
  family, friends)
• Be gently persistent

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If Then

• If the outlook is bleak (and it may well be),
  then check for suicidal thoughts (score 1)
• If the thoughts are persistent, intrusive and
  frequent (eg daily), then check for specific
  plans (how to get means, what pills and how to
  get them) (score 3)

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If Then

• If there are plans, then check if the self injury
  was part of the plan (Do not assume)
• Check whether the young person wishes to die,
  realising that this is a long term solution to
  what may be short term problems

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If Then

• You already know of the self harm (score 4)
• If the young person has threatened someone they
  will die then score an additional 2
• If the score from thoughts, threats, plans,
  attempts or the self harm is only 4 (the self
  harm), you should be able to manage

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If Then

• If the young person actively seeks to die, then
  ask about previous attempts (score 5)
• Check for Intent (Did they seek to die at that
  time?) (score an additional 1)
• Check for Lethality (score an additional 1)

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If Then

• If the total score is 5 - 7, then you may need to
  seek help with the management
• If the score is 8 or above then the young person
  may be not only self-harming, but also at serious
  risk of suicide. You may have to hospitalise.
• Never take the decision alone

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If Then

• If at all possible, involve the family or some
  other person or agency in the community
• Never carry the load alone - its not clever!

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Therapy

• Brief Focused Therapies
• CBT
• Narrative
• Solution Focused Family Therapy
• Group based semi-manualised IPT
• Manage with admissions under the young persons
  control

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What young people thought would be helpful (UK
Self harm report 2005)
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Current Programs

• SIMS Study Adolescent Ward, RBH
• National Epidemiological Study (ARC)
• RCT Group Therapy in 12-17 year olds
• SI Internet Site evaluation study
• Neurobiology of SI (using fMRI)
• Development of Training Materials (Rotary)
• Another 15 ideas in development

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Resources

• Selekman, MD (2002). Living on the razors edge
  Solution-oriented brief family therapy with
  self-harming adolescents. New York, Norton.
• www.focusas.com/SelfInjury.html
• www.siari.co.uk/
• www.angelfire.com/md2/simianline/selfinjury.html