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New Developments in Understanding

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Title: New Developments in Understanding


1
New Developments in Understanding Treating
Self-Injury
  • Presenter
  • Barent Walsh, Ph.D.
  • Executive Director
  • The Bridge of Central Massachusetts, Inc.
  • 4 Mann Street
  • Worcester, MA 01602
  • Phone 508-755-0333
  • email barryw_at_thebridgecm.org

2
Differential Classification of Self-damaging
Behavior
DIRECT
INDIRECT
High Lethality
Suicide SINGLE EPISODE
Situational Risk-TakingSINGLE EPISODE
Suicide Repeaters MULTIPLE EPISODES
High Risk Stunts Late Phase Anorexia MULTIPLE
EPISODES
Medium Lethality
Atypical or Major Self-Injury SINGLE EPISODE
Acute DrunkennessSexual Risk-Taking SINGLE
EPISODE
Chronic Substance Abuse, Bulimia, D/C
Psychotropic Meds MULTIPLE EPISODES
Low Lethality
Common Self-Injury MULTIPLE EPISODES
Modified, Pattison Kahan (1983)
3
Checklist for Direct Self-Harm Behaviors
  • Suicide Attempts__ Overdose __
    Hanging__Self-Poisoning __ Use of gun __
    Jumping from height
  • Major Self-mutilation __ Self-enucleation __
    Autocastration
  • Atypical Self-Injury __ Injury to face, eyes,
    genitals, breasts __ Damage involving multiple
    sutures
  • Common Forms of Self-Injury __ Wrist, arm and
    leg cutting __ Self-burning, self-hitting,
    excoriation

4
Checklist for Indirect Self-Harm Behaviors
  • Substance Abuse __ Alcohol Abuse __ Marijuana
    Use __ Cocaine Use __ Inhalant Use (glue,
    gasoline) __ IV Drug Use __ Hallucinogens,
    Ecstasy __ Other (specify)
  • Eating Disordered Behavior __ Anorexia Nervosa
    __ Bulimia __ Obesity __ Use of laxatives __
    Other (specify)

5
Checklist for Indirect Self-Harm Behaviors
(cont)
  • Physical Risk Taking __ Walking on high-pitched
    roof __ Walking in fast traffic
  • Situational Risk Taking __ Getting into
    strangers cars __ Walking alone in dangerous
    areas
  • Sexual Risk Taking __ Having sex with strangers,
    unprotected anal sex
  • Unauthorized discontinuance of psychotropic
    medications
  • Misuse/Abuse of prescribed psychotropic
    medications

6
Differentiating Suicide Attempts from Self-Injury
  • Q1. What was the expressed and unexpressed intent
    of the act?

SUICIDE ATTEMPT (Shneidman) To escape pain, to
terminate consciousness
SELF-INJURY (Walsh) Relief from unpleasant
affect (tension, anger, anxiety, sadness,
emptiness)
7
Differentiating Suicide Attempts from Self-Injury
  • Q2. What was the level of physical damage and
    potential lethality?

SUICIDE ATTEMPT Serious physical damage, lethal
means of self-injury
SELF-INJURY Little physical damage, non-lethal
means used
8
Differentiating Suicide Attempts from Self-Injury
  • Q3. Is there a chronic, repetitive pattern of
    self-injurious acts?

SUICIDE ATTEMPT Rarely a chronic repetition, some
overdose repeatedly
SELF-INJURY Frequently a chronic, high rate
pattern
9
Differentiating Suicide Attempts from Self-Injury
  • Q4. Have multiple methods of self-injury been
    used over time?

SUICIDE ATTEMPT Usually one method
SELF-INJURY Usually more than one method over time
10
Differentiating Suicide Attempts from Self-Injury
  • Q5. What is the level of psychological pain?

SUICIDE ATTEMPT Unendurable and persistent
SELF-INJURY Uncomfortable and intermittent
11
Differentiating Suicide Attempts from Self-Injury
  • Q6. Is there constriction of cognition?

SUICIDE ATTEMPT Extreme constriction, suicide as
only way out, tunnel vision, seeking final
solution
SELF-INJURY Little or no constriction, choices
available, seeking a temporary solution
12
Differentiating Suicide Attempts from Self-Injury
  • Q7. Do they feel hopeless and helpless?

SUICIDE ATTEMPT Hopelessness and helplessness
are central to their dilemma
SELF-INJURY Periods of optimism, some sense of
control over their own situations
13
Differentiating Suicide Attempts from Self-Injury
  • Q8. Was their a decrease in discomfort following
    the act?

SUICIDE ATTEMPT No immediate improvement,
treatment required for improvement
SELF-INJURY Rapid improvement, rapid return to
usual cognition and affect, successful
alteration of consciousness
14
Differentiating Suicide Attempts from Self-Injury
  • Q9. What is the core problem?

SUICIDE ATTEMPT Depression, rage about their
inescapable, unendurable pain
SELF-INJURY Body alienation, exceptionally poor
body image for clinical populations
15
Cautionary Notes Self-Injury vs. Suicidal
Behavior
While self-injury is generally not about suicide,
some individuals who self-injure do become
suicidal. It is important to emphasize that
while the behaviors are distinct, both can occur
within the same individual.
16
Cautionary Notes Self-Injury vs. Suicidal
Behavior
In a recent survey, Nock and Kessler (2006)
reported that individuals who cited suicide as
their reason for self-injuring (as opposed to
emotion regulation or interpersonal functions)
were more likely to ultimately die by suicide.
17
Increased Prevalence of Self-Injury in the U.S.
Early 1980s 400 per 100,000 Late 1980s 750 per
100,000 Late 1990s 1000 per 100,000
Today, an estimated 150,000 to 360,000
adolescents self-injure in the U.S.
18
Prevalence Details Re SI
  • In community samples, a range of 15 to 20 of
    youth report self-injuring at least once
  • In clinical samples, more females report SI than
    males In community samples there is no gender
    difference
  • Age of onset for the majority is 13 to 15 for a
    minority it can be younger.
  • SI may be more common among Caucasians GLBTQ
    youth (Nixon Heath, 2008)

19
Increased Prevalence of Self-Injury in the U.S.
Data from the 2005 Massachusetts YRBS indicated
that 19 of high school students in Massachusetts
reported having self-injured during the past
year. Also, a recent study from Cornell and
Princeton Universities, using a sample of almost
3000 students, found that 17 indicated having
self-injured (Whitlock et al. 2006b).
20
Groups in Which Self-Injury Was Commonly Reported
From 1960 to 1990
  • Outpatients with serious emotional disturbance
    or mental illness
  • Persons presenting at psychiatric emergency
    rooms
  • Seriously persistently mentally ill persons
    in day treatment or partial hospitalization
    programs

21
Groups in Which Self-Injury Was Commonly Reported
From 1960 to 1990
  • Seriously and persistently mentally ill
    adults living in community-based residential
    or supported housing programs
  • Patients in short and long-term psychiatric
    units
  • Youth in special education/residential schools
  • Prison inmates

22
Groups in Which Self-Injury Is Now Commonly
Reported
Since 1990
  • Youth in middle and high schools serving regular
    education students
  • Young adults enrolled in colleges and
    universities
  • Adults in the community at large

23
Speculations Regarding the Increased Prevalence
of SI
SocioCultural Influences
  • School and work environments are fraught with
    high levels of stress
  • Multi-tasking lifestyles are conducive to
    persistent low-level stress and anxiety
  • Heavy emphasis on competition in schools the
    workplace is conducive to isolation distrust

24
Speculations Regarding the Increased Prevalence
of SI
SocioCultural Influences, cont
  • Youth enter into intimate relationships at an
    earlier age, resulting in a level of emotional
    intensity for which they may not be prepared
  • The media heavily market a reliance on
    over- the-counter and prescription medications
    to alter mood, achieve desired feeling

25
Speculations Regarding the Increased Prevalence
of SI
SocioCultural Influences, cont
  • Modification of consciousness is viewed as
    something that can be quickly and affordably
    achieved via use of alcohol or street drugs.
  • Families, schools, and peers rarely teach
    healthy self-soothing skills.
  • Helicopter parents ??

26
Speculations Regarding the Increased Prevalence
of SI
Direct Modeling Influences in the Media
  • Popular television shows, music videos and
    movies portray self-injurers
  • People prominent in the media report
    self-injuring (Angelina Jolie, Princess Diana,
    Johnny Depp, Shirley Manson)
  • Many Web sites and chat rooms are dedicated to
    topic of self-injury (Whitlock et al., 2006a)

27
Speculations Regarding the Increased Prevalence
of SI
Adolescent Peer Group Dimensions
  • Adolescents routinely experience powerful
    emotions and lack the coping skills to manage
    them.
  • Adolescent peer groups view extensive substance
    use as a normative rite of passage.

28
Speculations Regarding the Increased Prevalence
of SI
Adolescent Peer Group Dimensions, cont
  • Substance use often begins at early ages, in
    middle and even grammar school.
  • Substance use forestalls normative
    problem solving and the development of healthy
    self-soothing skills.

29
Speculations Regarding the Increased Prevalence
of SI
Adolescent Peer Group Dimensions, cont
  • Adolescents place high value on being viewed as
    outrageous outsiders by peers and adults.
  • Peer group cohesion is enhanced by behaviors
    that adults condemn or fear.

30
Speculations Regarding the Increased Prevalence
of SI
Adolescent Peer Group Dimensions, cont
  • Youth are action-oriented. Self-injury is
    dramatic, visible, and produces immediate
    results.
  • Self-injury is viewed as not much different
    from these popular forms of body art or
    modification.

31
Speculations Regarding the Increased Prevalence
of SI
Internal Psychological Elements
  • Self-injury works it (temporarily) reduces
    tension and restores a sense of psychological
    equilibrium.
  • Self-injury has powerful communication aspects.
  • Self-injury provides a sense of control and
    empowerment

32
Biological Elements in Self-Injury
  • Psychiatric diagnoses associated with biological
    vulnerabilities (e.g. BPD, depression,
    schizophrenia, bipolar illness)
  • Limbic system dysfunction and the link to
    positive response to anticonvulsants (e.g.
    tegretol, depakote)

33
Biological Elements in Self-Injury
  • Serotonin levels and the link to diminished
    serotonin levels, impulsive aggression, and
    self-injury (with consideration to those who
    respond positively to SSRIs)

34
Endogenous Opioid System
EOS link to analgesia during self-injury
Addiction hypothesis - some support for this
hypothesis is found indirectly in successful
treatments using naltrexone.
Pain hypothesis - individuals have a
constitutionally underperforming EOS that is
unmasked by the environment.
35
Diminished Pain Sensitivity
Some self-injurers have diminished responsiveness
to pain as demonstrated in controlled laboratory
tests (e.g. cold pressor and tourniquet pain
tests). SI individuals show a increased
threshold for pain even when they are not
distressed.
36
Definition of Self-Injury
"Self-Injury is intentional, non-life-threatening,
self-effected bodily harm or disfigurement of a
socially unacceptable nature, performed to reduce
psychological distress." (Walsh, 2006)
37
Eight Levels of Care in the Treatment of
Self-Injury
  • I. The Informal Response
  • The Importance of Language
  • Interpersonal Demeanor
  • II. Crisis Intervention
  • Level of Physical Damage
  • Bodily Location

38
Eight Levels of Care in the Treatment of
Self-Injury
  • III. Behavioral Assessment Contingency
    Management
  • Environmental, Cognitive, Affective Behavioral
    Concomitants

39
Assessing Self-Injury
  • Antecedents (Events in Environment)
  • Antecedents (Biological Elements)
  • Antecedents (Thoughts, Feelings, Behaviors)
  • Wounds
  • Start Time of SIB Episode
  • End Time of SIB Episode
  • Extent of Physical Damage (Length, Width
    Were Sutures Obtained? If Yes, How Many?)
  • Body Area(s)

40
Assessing Self-Injury, continued
  • 9. Use of Tool- (Yes/No-If Yes, Type)
  • Room or Place of SIB
  • Alone or With Others During SIB
  • Aftermath of SIB (Thoughts, Feelings, Behaviors)
  • Aftermath of SIB (Biological Elements)
  • Aftermath of SIB (Events in Environment)
  • Reactions of Others to Your SIB
  • Other idiosyncratic details

41
Eight Levels of Care in the Treatment of
Self-Injury
  • IV. Replacement Skills Training
  • Negative Replacement Behaviors
  • Mindful Breathing
  • Visualization
  • Non-Competitive Physical Exercise
  • Writing - Playing/Listening to Music - Artistic
    Expression
  • Diversion Techniques

42
Eight Levels of Care in the Treatment of
Self-Injury
  • V. Cognitive Treatment
  • Identifying Triggers Using Them to Practice
    Replacement Skills
  • Identifying Automatic Thoughts, Intermediate
    Beliefs, and Core Beliefs That Support SI
  • Replacing Negative Cognitions with Adaptive
    Thoughts and Beliefs
  • The Key Role of Body Image

43
Eight Levels of Care in the Treatment of
Self-Injury
  • VI. Exposure Treatment for Resolution of Trauma
  • The Link Between Sexual Abuse, Body Alienation,
    and Recurrent Self-Injury
  • Resolving the Effects of Trauma via Exposure
    Treatment
  • Other Sources for Body Alienation and Related
    Self-Injury

44
Eight Levels of Care in the Treatment of
Self-Injury
  • VII. Group Treatment of Contagion
  • Avoiding Group Activities that Promote Contagion
  • Using Groups for Skills Training

45
Eight Levels of Care in the Treatment of
Self-Injury
  • VIII. Family Treatment
  • Teaching Families to Understand Manage
    Self-Injury Strategically
  • Resolving Family Dilemmas that Support Self
    Injury
  • Teaching Families Replacement Skills

46
Basic Features of a School Protocol to Manage SI
Staff Training
  • This protocol can only be implemented with
    adequate advance training of school staff.
  • Staff is trained regarding the forms of direct
    and indirect self-harm and how to provide a
    thorough assessment.
  • Staff is trained to understand how self-injury
    and suicidal behavior are markedly different in
    terms of 9 characteristics.

47
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals
  • School Administration identifies point persons to
    be contacted when self-destructive behavior
    surfaces within the school. Point persons are
    usually guidance counselors, social workers
    and/or school nurses.

48
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals
  • Staff refers all students with self-destructive
    behavior or plans to the designated point
    persons. Point persons assess whether the
    behavior should be considered suicidal behavior,
    other life-threatening behavior, or common, low
    lethality self-injury.

49
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals
  • If the behavior or plan is deemed to be suicidal
    or otherwise life-threatening, emergency
    procedures are followed.

50
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals
  • If the behavior is deemed to be common
    self-injury, the point person calls the students
    parent while the student is present.
  • The point person explains that he/ she has
    learned the child has self-injured and explains
    that the behavior is cause for concern but not
    usually about suicide.

51
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals
  • The point person requests that the parent follow
    up immediately with outpatient counseling for the
    child and family.
  • The point person requests that the parent call
    back to confirm that the outpatient appointment
    has been made.

52
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals
  • If the parent does not call back, the point
    person re-contacts the parent and requests that
    the outpatient referral be pursued.
  • If after repeated requests the parent fails to
    act, mandated reporting for neglect or abuse must
    be considered

53
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals
  • The point person generally stays in periodic
    contact with the parent to monitor progress.
  • In some cases, the point person obtains consent
    from parent and child to communicate with the
    outpatient clinician.

54
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury Among Groups
  • Point persons should assess if multiple students
    are triggering the behavior in each other.

55
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury Among Groups
2. Contagion may be due to the following
influences a. Limited communication skills b.
Desire to change the behavior of others c.
Response to caregivers, family members -
Competition for caregiver resources -
Anticipation of aversive consequences
56
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury Among Groups
2. Contagion may be due to the following
influences d. Other peer group influences
- Direct modeling influences -
Disinhibition - Competition - The role of
peer hierarchies - Desire for group cohesiveness
57
Basic Features of a School Protocol to Manage SI
Managing Preventing Contagion
  • Point persons identify the primary high status
    peer models.
  • Use of a contagion map or sociogram can be
    helpful.

58
Schematic Representation of Self-Injury Contagion
59
Basic Features of a School Protocol to Manage SI
Managing Preventing Contagion
  • Point persons explain to peer models that they
    are hurting their peers by communicating about SI
    to others.
  • Self-injurers are encouraged to talk with
    the point persons, family, therapists, but not to
    peers about SI as such talk is triggering.

60
Basic Features of a School Protocol to Manage SI
Managing Preventing Contagion
  • Students are asked not to appear in school with
    visible wounds or scars
  • Point persons involve parents when necessary
  • Some students may need to have extra sets of
    clothing in school to cover wounds or scars.
  • In rare cases, students may have to be dealt with
    disciplinarily

61
Diverse Cognitive Processes and their Role in SI
CORE BELIEFSIm incompetent. Im unlovable.
INTERMEDIATE BELIEFS (attitudes, rules,
assumptions) Attitude I deserve all this
emotional pain. Rule Self-injury reduces pain
better than anything else. Assumption It will
always be this way.
AUTOMATIC THOUGHTS Get the razor! I need to act!
62
Before After CognitionKey Automatic Thoughts
Cognitions that Support SI
Alternative Adaptive Thoughts
  • With these emotions, I have to cut now
  • Self-injury provides such quick relief
  • Self-injury causes others to respond to me
  • I can use my new skills to manage emotion
  • Self-injury has long term negative effects
  • Self-injury causes many to avoid me

63
Before After CognitionIntermediate Beliefs
Alternative Adaptive Thoughts
Cognitions that Support SI
  • I deserve this rejection
  • Self-injury works immediately
  • I deserve someone who treats me with respect
  • I can live with some discomfort while I use my
    skills.

64
Before After CognitionIntermediate Beliefs
Cognitions that Support SI
Alternative Adaptive Thoughts
  • Self-injury is the best solution
  • Self-injury works immediately
  • Self-injury is one of many solutions and not
    necessarily the best.
  • I can live with some discomfort while I use my
    skills. I can surf the urge to self-injure.

65
Before After CognitionCore Beliefs
Cognitions that Support SI
Alternative Adaptive Thoughts
  • Im unlovable
  • Im incompetent
  • A number of people truly care for me
  • Im a competent worker cook

66
Recommended Reading
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67
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