Helping Teens and Families Manage SelfInjurious Behavior

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Helping Teens and Families Manage
Self-Injurious Behavior

• March, 2007
• Kim Poling, LCSW
• Services for Teens at Risk

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Objectives

• Distinguish suicidal behavior from non-suicidal
  self-injury
• Review strategies for assessing suicide risk and
  negotiating the Safety Plan
• Review facts about SIB
• Overview of strategies for intervening with SIB.

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Objectives (continued)

• Review importance of establishing the treatment
  contract.
• Learn chain analysis as a strategy to both assess
  and treat self-destructive behavior.
• Learn to teach emotion regulation skills to both
  teens and family to help reduce self-injurious
  behavior.

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Emotion Regulation Skills to be covered

• Affect education
• Decreasing vulnerability to emotional
  dysregulation
• Use of the freeze frame (chain analysis)
• Mindfulness of your current emotion
• Opposite action
• Distress tolerance

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Assessing Suicidality General Guidelines

• An ongoing process for adolescents at risk.
• Do not be afraid of asking about suicidal
  thoughts and plans.
• Begin with general questions, move to more
  specific.
• Be gently persistent in seeking details.

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Assessment of Suicidal Ideation

• Have you ever thought you would be better off
  dead?
• Do you have thoughts of wanting to hurt yourself?
  (intensity and frequency)
• Do you have a plan?
• Do you intend to carry it out?
• What things keep you from acting on your thoughts
  (Reasons for Living)?
• What things would increase the likelihood of
  trying to hurt yourself?

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More questions about suicidal thoughts

• How likely to act
• How likely able to resist
• Circumstances (when intoxicated, psychotic)
• Availability of lethal agent
• Wish to live vs. wish to die

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Suicidal Intent

• Wish to die (based on self-report and/or
  observable behavior
• Belief about intent
• Preparatory behavior
• Prevention of discovery
• Communication of intent
• Higher in completers than attempters
• Predicts reattempt and completion
• Are you sorry that you did not die / glad you are
  alive?

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Motivation (What were you hoping would happen
as a result of this?)

• Wish to die or permanently escape psychological
  painful situation (1/3 in younger individuals,
  but increases with age)
• To influence others
• Get attention
• Express hostility or other emotions
• Induce guilt

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Precipitants

• Family discord/conflict
• Abuse
• Romantic attachment disruption
• Legal/disciplinary problems
• Disruption of relationship very high risk for
  alcoholic suicides
• Assess likelihood of recurrence

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Psychopathology

• Over 80 of attempters and 90 of completers have
  at least one Axis I disorder
• Most commonly mood disorder
• High risk for bipolar disorder, particularly
  mixed state
• Substance abuse
• Cluster B disorders
• Conduct disorder
• Comorbidity, chronicity, severity

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Psychological Characteristics

• Hopelessness (dropout, poor treatment response,
  attempt)
• Impulsivity and aggression (strong predictor of
  suicidal behavior, especially in presence of a
  mood disorder, familial component) - More
  important in suicide earlier in life
• Social skills deficits (interpersonal problems)
• Homosexuality, bisexuality (bullying, family
  rejection)
• Inflexibility (in older suicides)

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Suicide Continuum
Passive Death Wish
Suicidal Ideation, no method
Suicidal Ideation with method
Attempt
Completion
Gesture
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Assessing Current Safety

• Assess the presence or absence of suicidality and
  the degree of severity (frequency, intensity,
  duration) over the past 48 hours or since last
  visit.
• Negotiate Safety Plan.
• Collaborate and review this plan with family.
• If family conflict is a common precipitant to
  suicidality or self harm, help teen and family
  negotiate a truce.

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Elements of the Safety Plan

• Research suggests a signed written contract is
  not meaningful to patients.
• The safety plan is preferable to the no-suicide
  contract-- it is more than a promise not to act
  on suicidal thoughts.
• The safety plan is a detailed plan for dealing
  with a suicidal crisis.
• The safety plan is tailor-made for the teen with
  the teen and parents.
• Includes the phone numbers of trusted adults,
  therapist, 24-hour emergency coverage.

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Developing the Safety Plan

• Negotiate with teen to defer acting on suicide
  for a specified period in order to try other
  potential solutions he/she may not have
  considered.
• Therapist and teen identify vulnerability factors
  (social contexts, events, themes, songs,
  substances, etc.) that tend to trigger suicidal
  thinking.
• Negotiate with teen to avoid activities that may
  increase suicidal feelings for a period of time.

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Developing the Safety Plan (Cont.)

• Safety plan includes coping strategies to use in
  a suicidal crisis.
• Develop a coping card with written strategies
  and instructions in case of emergency, which teen
  agrees to carry.
• Involve parents family may need to agree to call
  a truce on hot topics until teen is stable.
• Assess teens confidence in his/her ability to
  follow the safety plan.

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Developing Safety Plan (Cont.)

• Discuss ALL possible obstacles to keeping the
  safety plan.
• Problem-solve these obstacles with teen and
  parents.
• Trust your clinical instincts (eye contact, body
  language) if you doubt teen is sincere.

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Hopelessness

• Address hopelessness about treatment first.
• On a scale of 1-10, how hopeful are you that we
  can help you? What would increase/decrease it?
• Establish concrete, realistic, achievable goals.
• Reasons for living.
• Predict bumps in the road to prevent undue
  discouragement.

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Secure Lethal Agents

• Find out motivation for gun ownership.
• Find out who owns the gun.
• Negotiate most secure situation possible.
• Parental regulation of medication.

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Self-Injurious Behavior
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Distinguishing SIB from Suicidal Behavior

• Suicidal behavior is distinct from SIB in terms
  of motivation, intent, and lethality.
• Suicidal behavior is accompanied by some degree
  of wish to die and intent to die i.e. the
  patient believes that the behavior will possibly,
  or will definitely, result in death.
• Carefully assess motivations (to die, to escape,
  to influence someone, to communicate feelings, to
  relieve emotional distress, and intent (what was
  the expected outcome of the behavior?)

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Prevalence of SIB

• Community samples in the U.S. vary in estimates
  from 4 to 38 of adolescents.
• Among patients with eating disorders, 34.6 had a
  life-time rate of SIB (N376) (Paul et al, 2002).
• Canadian study found 13.9 of urban and suburban
  high school students had self-injured (Ross
  Heath, 2002).
• A British report noted a 65 increase in SIB
  disclosures to national childrens hotlines from
  1999 to 2004.

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Types of Self-Injury

• Superficial self-injurious behavior (SIB) such as
  self-cutting, scraping, burning (associated with
  Cluster B personality disorders, eating
  disorders, stress disorders)
• Repetitive Stereotypical Behavior such as head
  banging and self biting (associated with
  intellectual disability, e.g. MR, autism)
• Major self mutilation such as self blinding and
  castration (rare occurs in psychotic disorders
  and substance intoxication) Harris, JC, 2005

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Self-Injury

• To relieve distress/anger, pain, loneliness
  rather than to die
• Often co-occurs with suicidal behavior

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Negotiating Treatment Contract

• Initially patients with history of self-cutting
  may not be able to agree to abstain entirely from
  SIB.
• Explore teens concerns about their SIB and
  negative consequences of the behavior to increase
  motivation for change (remain non-judgmental).
• Negotiate with teen to try specific emotion
  regulation strategies first, and to delay cutting
  for longer periods after the urge begins.
• Negotiate with teen to avoid triggers for
  self-injury.

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Understanding Self-injurious Behavior

• SIB is identified by the patient as non-suicidal,
  and is typically aimed at relieving distress. It
  is marked by
• An irresistible impulse to self-harm
• Mounting agitation no escape from tension
• Cognitive constriction- no alternatives
  considered
• Rapid, temporary relief following the act of self
  injury

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Functions Self-injury may Serve

• Escape or reduce painful emotions
• Distract from painful memories or thoughts
• Self-expression of emotions
• Punishment of self
• Tension reduction/Anger reduction
• Get attention, social support, or help
• To feel alive

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Characteristics of Self-injurers

• The teen may have difficulties
• Labeling their emotions
• Effectively regulating emotions
• Trusting experiences as valid responses to events
  (therefore individual searches environment for
  cues about how to respond)
• Tolerating distress
• Effectively solving problems (Miller, 1999)

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Emotional Vulnerability

• High sensitivity
• Immediate reactions
• Low threshold for emotional reaction
• High reactivity
• Extreme reactions
• High arousal dysregulates cognitive processing
• Slow return to baseline
• Long lasting reactions
• Creates high sensitivity to next emotional
  stimulus

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Facts about Self-Injurious Behavior

• It occurs most often in the context of borderline
  personality disorder.
• High of individuals with BPD have self injured
  (65-85).
• Can occur in the context of MDD without BPD.
• Occurs also in developmentally disabled.
• It is often a hidden behavior.

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Facts about SIB (continued)

• Although it has a restorative value, it is
  often accompanied by shame.
• It is primarily NOT a manipulative behavior.
• Precipitant is often interpersonal rejection or
  disappointment in self that leads to self
  condemnation.
• Intent is primarily to affect INTRApersonal not
  INTERpersonal state.

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Facts about SIB (continued)

• Individuals who self injure can distinguish most
  of the time whether the behavior is a suicide
  attempt or SIB.
• Individuals who engage in SIB are at greatly
  increased risk for suicidal behavior.
• SIB is the most predictive risk factor for
  suicide attempts.

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What We See in the Teen

• Critical, hostile statements toward self and
  feelings of guilt, shame, anger when experiencing
  strong emotions
• These reactions serve to intensify the pain of
  the original emotion and further support the
  self-critical backlash

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Creating a Validating Therapeutic Environment

• Therapist validates the emotional need behind the
  behavior.
• Therapist must non-judgmentally acknowledge
  destructiveness of teens behavior.
• Youre doing the best you can, and you can do
  better.
• Therapist refrains from criticizing the
  individual but instead elicits negative
  consequences about specific behaviors from teen.

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Treatment Guidelines

• Establish safety plan
• Increase likelihood of adherence
• Determine appropriate level/intensity of care
• Increase hopefulness about treatment

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Treatment Guidelines (continued)

• Increase protective factors (family connection)
• Coping plan, hope kit
• Conduct chain analysis of the attempt
• Target most relevant individual and environment
  factors to the suicide attempt, especially
  emotions and cognitions lead to attempt

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Strategies

• Distinguish between SIB and suicide attempt
• Chain Analysis
• Determine the precipitants and functions of the
  SIB

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Strategies (continued)

• Develop understanding of why precipitants provoke
  SIB and strategies to counteract (if cognitive
  distortions develop alternative explanations
  and challenges)
• Develop other means of providing the function of
  SIB (if function is emotion restoration and
  regulation then develop emotion regulation
  skills)

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Chain analysis as a Guide to Case
Conceptualization

• A form of behavioral analysis
• Translation of the behavior problem (SIB) into
  links in the chain of emotions, events,
  behavior and consequences
• Assessing at a micro-level to reconstruct the
  sequence in time

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Chain Analysis as a Guide

• Start by asking teen to walk you through the
  events that led up to the self-injury.
• Help teen identify vulnerability factors that may
  have contributed.
• Ask teen to describe in detail the precipitants,
  thoughts, images, and feelings they may have
  experienced as well as what was going on
  outside.
• Ask about () and (-) consequences of the SIB.

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Links in the Chain

• Vulnerability factors
• Triggering event
• Emotions
• Thoughts (self-talk)
• Physical sensations
• Urges
• Behavior
• Consequences

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Forming Conceptualization

• The specific vulnerabilities, self-statements,
  and feelings (internal factors), as well as the
  triggering events and consequences of the SIB
  (external factors), will help you to develop
  the case conceptualization and treatment plan.

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Prioritize Treatment Needs

• Through chain analyses, the therapist decides
  which skill areas to target first
• Emotion regulation skills
• Cognitive restructuring
• Family conflict
• Communication skills
• Problem-solving
• Social skills/assertiveness skills

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BREAK !
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Emotion Education

• Learning to be nonjudgmental toward self
• Teach teen how to observe and describe different
  emotions, without labeling them as good or bad,
  but simply to be aware of them.
• Emotion dysregulation results often because teen
  is overly harsh toward self for having strong
  feelings, and may often judge specific feelings
  as wrong, or invalid, and feel more distressing
  emotions in turn.

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Emotion Education (continued)

• Action urges and choices
• A negative emotion often leads to an irresistible
  urge to act in a self-destructive manner.
• Important to teach teen that just because they
  have urge to act on a distressing emotion they
  are not obligated to act in this way.
• Distinguish between urge to act and the
  action itself.

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Reducing Vulnerability to Negative Emotion

• Parents and teens should be taught how to
  decrease vulnerabilities.
• Emphasis on importance of maintaining regular
  sleep schedule.
• Eating balanced diet, treating physical illness,
  getting regular exercise, avoiding substance
  abuse and planning at least one activity a day
  that elicits a sense of competence and mastery.

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HEAR ME

• Health (treat physical illness)
• Exercise regularly
• Avoid mood altering drugs
• Rest (balanced sleep)
• Mastery (one rewarding activity daily)
• Eating (balanced diet)

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Emotions Thermometer
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Mindfulness of current emotion

• Steps in the process
• 1. Observe your emotion
• 2. Experience your emotion
• 3. You are not your emotion
• 4. Practice accepting your emotion

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Mindfulness

• 1. Observe your emotion
• Note its presence just observe it
• Step Back
• Get Unstuck from the emotion

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Mindfulness

• 2. Experience Your Emotion
• As a wave, coming and going
• Try not to block or suppress the emotion
• Dont try to get rid of the emotion
• Dont push it away
• Dont try to keep the emotion around
• Dont hold on to it
• Dont intensify it

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Mindfulness

• 3. Remember You are not your emotion
• Do not necessarily act on your emotion (that is,
  let destructive action urges pass).
• Remember times when you have felt different.

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Mindfulness

• 4. Practice accepting your emotion
• Do not judge your emotion as wrong, bad, too
  painful, unfair, embarrassing, etc.
• Do not criticize yourself for feeling the
  emotion.
• Accept your emotion as it is in the moment.

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Chain Analysis as an Intervention The Freeze
Frame Technique (Wexler, 1991)

• Takes the chain analysis a step further
• Recalls events as if reviewing a video replay and
  then freezing the frame at critical points.
• Helps teen to slow time down (especially useful
  for teens who are impulsive and cant remember
  what happened) .

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Freeze Frame (continued)

• Needs-Important to teach teen that if they can
  identify their needs and learn different
  behaviors to get their needs met, they can have
  more power.
• Once you know the needs, you are smarter. Once
  you have new tools for handling the needs, you
  are more powerful (Wexler, 1993).

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Freeze Frame (continued)

• The Freeze Frame differs from the chain analysis,
  and becomes an intervention with the final step
• The teen replays the scene and replaces the
  problem behavior with the new coping skills, and
  then imagines a new outcome.

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Educating Family about Freeze Frame

• The Freeze Frame approach is the basis for
  generating options and interventions with regard
  to emotion dysregulation.
• We can use this approach to examine emotion
  dysregulation that occurs interpersonally between
  family members.

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Break
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Distress Tolerance Skills

• Vital skill to teach teen as they will not always
  be able to decrease painful emotions, or get what
  they need interpersonally, so they will need to
  learn how to tolerate distressing emotions.

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Distress Tolerance Skills

• Teaching teens to suspend judgment an emotion
  simply is
• Teaching teens to accept painful feelings vs.
  trying to get rid of them quickly

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Distress Tolerance Skills

• CBT component of Distress Tolerance
• Acceptance self-talk
• Learning to talk to yourself nonjudgmentally e.g.
  Im doing the best I can, I know if I can just
  get through this difficult time things will get
  better.
• Acceptance self-talk counters the negative,
  critical shoulds that often accompany painful
  emotions.

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Distress Tolerance Skills

• Main emphasis is teaching teens how to soothe
  themselves .
• Teens may be resistant to this, as their relation
  to the world is predominantly action and other
  oriented.

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Distress Tolerance Skills

• Some teens have belief that others should soothe
  them when distressed and have difficulty
  believing that they can depend on themselves.
• Others may feel that they dont deserve to be
  soothed and may feel guilty, ashamed, angry when
  they try to self-soothe (Linehan, 1993) .

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Self-Soothing Throughthe Five Senses

• An accessible and easily taught
  self-soothing/distress tolerance skill is the use
  of the 5 senses
• Vision, hearing, smell, taste, touch
• Usually at least 2-3 of the five senses are
  engaged or capable of being engaged at any given
  moment as a distraction from distress.

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Sensory Soothing (continued)

• Vision
• Focus on an aspect of nature, or any visual
  detail
• Hearing
• Music, nature sounds, relaxation tape, fan noise
• Smell
• Lotion, candle, perfume, favorite food cooking
• Taste
• Hot chocolate or tea, ice creamtaste slowly
• Touch
• Pet your dog, cat, soothing bath, hug, blanket

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Helping Parents Regulate Their Emotions When in
Conflict with Teen

• Teach strategies for changing the timing and
  process of confrontations.
• Important to educate parents that when teen
  attacks and parent becomes dysregulated then
  parent can no longer be effective in enforcing
  rules and consequences.
• Teens will escalate their behavior in an attempt
  to control outcome of mood and outcome of the
  interaction (Sells, 1998).

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Facilitating a Validating Family Environment

• Help both parents and teen to understand how
  their reactions to each other may be
  unintentionally invalidating.
• Kernel of Truth
• Coaching parents to become more aware of the ways
  in which their communication may be overly
  negative and critical.
• Validation isnt agreeing with and doesnt have
  to be warm and fuzzy.

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Family and Social Protective Factors in
Adolescents

• Parent-child connection
• High parental expectations
• Parental supervision and availability
• School connection
• Religious affiliation
• Non-deviant peer group

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Education

• Educate parents and families about difference
  between SIB and suicide attempt
• Does not usually require psychiatric
  hospitalization unless patient is actively
  suicidal
• It is not primarily attention seeking

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Education

• It is a serious behavior, can serve as a gate
  to suicidal behavior and therefore, needs
  treatment
• In the context of a suicidal person, can be a
  compromise to stave off suicide attempt

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Strategies to Help Parents Respond Calmly

• Strategies to help parents respond calmly and
  nonreactively to their teens provocations during
  conflict
• Exit and Wait
• Staying short and to the point, using deflectors

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Communication Skills

• Active Listening (verbal and non verbal skills)
• Therapist models listening skills
• Sending clear messages ( use of I statements
  instead of you
• Practice/role play in session

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Changing Emotion by Acting Opposite the Current
Emotion

• Every emotion has an action associated with it.
• Fear Run
• Anger.. Attack
• Sadness..Withdraw
• Shame.Hide

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Changing Emotion by Acting Opposite the Current
Emotion

• Opposite Action
• Emotion is strongly influenced by our bodily
  posture and facial expressions.
• By altering posture, behavior and facial
  expressions, we can delay, interrupt or
  de-escalate the progression of a problematic
  emotion.

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Opposite Action for Anger

• Keep ones palms open when inclined to punch.
• Whisper when inclined to scream.
• Breath deeply and slowly rather than angrily
  hyperventilating.
• Gently avoid the person you are angry with rather
  than attacking.
• Put yourself in the other persons shoes, and
  imagine sympathy or empathy for the person,
  rather than blame.

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Opposite Action for Guilt or Shame

• Repair the mistake.
• Say youre sorry
• Make up for what you did to the person you
  offended
• Try to avoid making the same mistake in the
  future.
• Accept the consequences for what you did.
• Then let it go.

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Opposite action for Sadness or Depression

• Get active
• Approach, dont avoid
• Do things that make you feel effective and
  self-confident
• Use the half-smile

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Steps to practice using opposite action

• What emotion am I experiencing?
• What is the action (what is the emotion trying to
  get me to do)?
• Do I really want to reduce this emotion?
• What is the opposite action?
• DO the opposite action.
• Practice, practice, practice!

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Summary

• Important to assess most severe episode of
  suicidal thoughts or behavior and evaluate the
  precipitants and motivations.
• Important to gather history of suicidal thoughts
  and behaviors in all patients.
• Gather current information and history of
  self-injurious behaviors or urges.

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Summary (continued)

• Establish safety plan with teen and family. If
  conflict has been a precipitant, work with family
  to call a truce.
• Evaluate possible reinforcers for the teen to
  continue self-injurious behaviors (what does
  he/she get or gain). Remain non-judgmental.

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Summary (continued)

• Decrease vulnerability factors
• Teaching Use of Freeze Frame (chain analysis)
• Teach Emotion Regulation skills to teen and
  parents.
• Enhance Family Communication skills

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Summary (continued)

• Self-soothing skills
• Helping parents regulate their emotions when in
  conflict. Strategies to help.
• Changing Emotion by opposite action technique
• Distress Tolerance Skills

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We acknowledge with gratitude the Pennsylvania
Legislature for its support of the STAR-Center
and our outreach efforts.This presentation may
not be reproduced without written permission
from STAR-Center Outreach, Western Psychiatric
Institute and Clinic, 3811 OHara Street,
Pittsburgh, PA 15213. [phone]All Rights
Reserved, 2007