CUTTING AND OTHER SELF CUTTING AND OTHER SELF HARMING BEHAVIOR HARMING BEHAVIOR

IN ADOLESCENTSIN ADOLESCENTSPRESENTED BY:PRESENTED BY:

Janice Gabe, LCSW, MACJanice Gabe, LCSW, MACNew Perspectives of Indiana, Inc.New Perspectives of Indiana, Inc.

6314-A Rucker Road6314-A Rucker RoadIndianapolis, IN 46220Indianapolis, IN 46220

(317) 465-9688(317) 465-9688(317) 465-9689 Facsimile(317) 465-9689 Facsimile

www.newperspectives-indy.combarb6308@earthlink.netbarb6308@earthlink.net

HOW DO ADOLESCENTS HOW DO ADOLESCENTS PHYSICALLY SELF HARM?PHYSICALLY SELF HARM?

CuttingCutting StabbingStabbing Scratching the skinScratching the skin Scraping and rubbing skin, removing top Scraping and rubbing skin, removing top

layerlayer Placement of sharp objects under the skin Placement of sharp objects under the skin

or in body orificesor in body orifices Gnawing at the fleshGnawing at the flesh

Biting the inside of the mouth to make sores Biting the inside of the mouth to make sores then regularly re-opening themthen regularly re-opening them

Picking at woundsPicking at wounds Burning skin using heatBurning skin using heat Burning skin by using chemicals or caustic Burning skin by using chemicals or caustic

liquidsliquids Pulling hair out, including eyelashes and Pulling hair out, including eyelashes and

eyebrowseyebrows

HOW DO ADOLESCENTS PHYSICALLY HOW DO ADOLESCENTS PHYSICALLY SELF HARM?SELF HARM?

Hitting themselves hard enough to bruise Hitting themselves hard enough to bruise selfself

Banging head against somethingBanging head against something Tying items around neck, arms, legs to Tying items around neck, arms, legs to

restrict blood flowrestrict blood flow Ingesting small amounts of toxic substances, Ingesting small amounts of toxic substances,

enough to get sick but not enough to dieenough to get sick but not enough to die Ingesting self harming objects such as Ingesting self harming objects such as

straight pinsstraight pins

HOW DO ADOLESCENTS HOW DO ADOLESCENTS PHYSICALLY SELF HARM?PHYSICALLY SELF HARM?

SELF HARMING IS NOT SELF HARMING IS NOT NECESSARILY----NECESSARILY----

A suicide attemptA suicide attempt An indication of early childhood abuse or An indication of early childhood abuse or

traumatrauma An indication of sexual abuseAn indication of sexual abuse An indication of borderline personality An indication of borderline personality

disorderdisorder A behavior which is limited to femalesA behavior which is limited to females A bid for attentionA bid for attention

SELF HARM IS DIFFERENT SELF HARM IS DIFFERENT FROM-----FROM-----

Multiple body piercingMultiple body piercing

TattoosTattoos

BrandingBranding

UNDERSTANDING PATTERNS UNDERSTANDING PATTERNS OF SELF HARMINGOF SELF HARMING

I.I. WHO DOES IT?WHO DOES IT?A.A. 60% are young women between the ages of 60% are young women between the ages of

16 and 2516 and 25B.B. In this culture it appears to be largely a In this culture it appears to be largely a

Caucasian female issueCaucasian female issueC.C. 5% of adult self harmers report 5% of adult self harmers report

participating in this behavior in early participating in this behavior in early childhoodchildhood

D.D. It is entirely possible that early childhood It is entirely possible that early childhood self harm is not reported or recognizedself harm is not reported or recognized

E.E. With adults it is always connected to significant With adults it is always connected to significant and early childhood trauma. This is not and early childhood trauma. This is not

necessarily the case with teensnecessarily the case with teens

II.II. WHAT PURPOSE DOES IT SERVEWHAT PURPOSE DOES IT SERVE

A. A. The primary purpose of self harming The primary purpose of self harming is to relieve emotional tensionis to relieve emotional tension

B.B. Adolescent girls describe self Adolescent girls describe self harming harming as a way to obtain as a way to obtain relief from anxiety, relief from anxiety, agitation, agitation, angeranger

C.C. Adolescent females often describe self Adolescent females often describe self harming as the only way to harming as the only way to

tolerate tolerate intense feelings intense feelings without resorting to without resorting to suicidesuicide

D.D. Adolescent females report thatAdolescent females report thatself harming serves to:self harming serves to:

1. Provide emotional relief1. Provide emotional relief2. Alter their mood2. Alter their mood3. Stop obsessive and troublesome thoughts3. Stop obsessive and troublesome thoughts4. Stops them from behaving in a way that 4. Stops them from behaving in a way that

is is considered “bad” or “unacceptable” considered “bad” or “unacceptable”5. Communicate their anger at others 5. Communicate their anger at others

without without risking conflict or rejection risking conflict or rejection6. Express their anger toward themselves6. Express their anger toward themselves7. Punish themselves for bad things they 7. Punish themselves for bad things they

have have done or emotions they should not have done or emotions they should not have

8. Stop “voices of others” in their head8. Stop “voices of others” in their head

9. Stop thinking about trauma (if trauma 9. Stop thinking about trauma (if trauma has has been present in their past) been present in their past)

10. Turn their emotional pain into physical 10. Turn their emotional pain into physical pain pain

11. Help them not feel so dead or empty 11. Help them not feel so dead or empty inside inside

12. Bring about calming effects12. Bring about calming effects 13. To let others know that they have been 13. To let others know that they have been

hurt and that they have been hurt and that they have been damaged damaged by this hurt by this hurt

14. To obtain care and nurturing to the skin 14. To obtain care and nurturing to the skin and wound (perhaps as a way of and wound (perhaps as a way of repairing effects of earlier trauma repairing effects of earlier trauma

III.III. WHAT ARE MOTIVATIONSWHAT ARE MOTIVATIONSI. 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

III. About perceptions

IV. Communication

V. Emotions

V.V. WHAT ARE THE PATTERNS OFWHAT ARE THE PATTERNS OF

SELF HARM?SELF HARM?

A.A. Self harm is usually a solitary Self harm is usually a solitary experience. The exception to this experience. The exception to this

are are teens who are institutionalized teens who are institutionalized

B.B. Self harm is often learned from others. Self harm is often learned from others. Teens hear their friends talking Teens hear their friends talking

about it, about it, or see something about it on or see something about it on TV and TV and decide to try itdecide to try it

C.C. Self harm is often a secret, and is kept Self harm is often a secret, and is kept hidden from adults because the hidden from adults because the

teens are teens are ashamed and afraidashamed and afraid

D.D. Self harm is usually an ongoing behavior Self harm is usually an ongoing behavior once it comes to the attention of adults. once it comes to the attention of adults. Single incidents do not usually get Single incidents do not usually get

detecteddetected

E.E. Self harm takes on an addictive Self harm takes on an addictive dimension. dimension. Teens like the predictable Teens like the predictable results and find results and find it rewarding so they repeat itit rewarding so they repeat it

F.F. Self harm is often progressive in nature, Self harm is often progressive in nature, they have to do more and more of it in they have to do more and more of it in

order to get the desired resultorder to get the desired result

V.V. WHAT ARE THE BIOLOGICAL WHAT ARE THE BIOLOGICAL RESULTS OF SELF HARMING?RESULTS OF SELF HARMING?

A. Self harming produces the release of A. Self harming produces the release of endogenous opioids. These are endogenous opioids. These are neurochemicals similar to drugs neurochemicals similar to drugs

like heroin. like heroin. They produce a feeling of They produce a feeling of calm and well-calm and well- being. They are naturally being. They are naturally released in the released in the brain when a person brain when a person feels danger or fear, or feels danger or fear, or when a person is when a person is injured. This will enhance injured. This will enhance a persons a persons ability to survive the traumaability to survive the trauma

B. Environmental stimuli can trigger a B. Environmental stimuli can trigger a trauma reaction and thus, the release trauma reaction and thus, the release

of of opioids opioids

C.C. We can become addicted to our own We can become addicted to our own endogenous opioids and need more endogenous opioids and need more

to to be released to experience a sense of be released to experience a sense of calm. Self harming is one way to get calm. Self harming is one way to get the body to do the body to do thisthis

D.D. Endogenous opioids are natural Endogenous opioids are natural pain pain killers, this may be why some killers, this may be why some girls say girls say they they do not feel their paindo not feel their pain

E.E. When girls stop the self harming, they may When girls stop the self harming, they may experience withdrawal from these opioids experience withdrawal from these opioids which may increase their agitation and which may increase their agitation and anxiety which in turn, triggers urges to anxiety which in turn, triggers urges to continue to self harmcontinue to self harm

F.F. When people are exposed to high levels of When people are exposed to high levels of stress, they experience low levels of serotonin. stress, they experience low levels of serotonin. Low levels of serotonin are linked to Low levels of serotonin are linked to impulsive behavior and lack of constraint. impulsive behavior and lack of constraint. Therefore, this makes it easier to indulge in Therefore, this makes it easier to indulge in self harming and more challenging to stopself harming and more challenging to stop

TREATMENT INTERVENTIONSTREATMENT INTERVENTIONS

I.I. CREATING THE APPROPRIATE CREATING THE APPROPRIATE ATMOSPHEREATMOSPHERE

A. Teens have to be able to talk about it A. Teens have to be able to talk about it when it when it happens. They won’t do this if happens. They won’t do this if they feel they feel shamed or embarrassed or shamed or embarrassed or sense you are sense you are uncomfortable with uncomfortable with them talking about itthem talking about it

B. The role of the professional is to make it clear B. The role of the professional is to make it clear you disapprove of the behavior, but not you disapprove of the behavior, but not

them them as a person. They need to know that the as a person. They need to know that the goal goal is for them to abstain, but this is clearly is for them to abstain, but this is clearly a a therapeutic vs. a punitive goal therapeutic vs. a punitive goal

C.C. How well they respond to therapy How well they respond to therapy depends depends a great deal more on their a great deal more on their relationship with relationship with the helper than any the helper than any specific therapeutic specific therapeutic orientationorientation

D.D. The adolescents need to know you will The adolescents need to know you will not not be shocked or overwhelmed by their be shocked or overwhelmed by their behaviorbehavior

II.II. DISCOVERING WHAT IT MEANS TO DISCOVERING WHAT IT MEANS TO THEMTHEM

A.A. One of the first steps in therapy is One of the first steps in therapy is to to decide what role or purpose the self decide what role or purpose the self

harm has for this individual harm has for this individual adolescent. adolescent. We have to be cautious We have to be cautious not to generalize not to generalize what it usually means. what it usually means. Teens feel Teens feel devalued when we devalued when we approach them this approach them this wayway

B.B. Help the teen recognize her pattern. Talking and Help the teen recognize her pattern. Talking and journaling are excellent tools for helping with journaling are excellent tools for helping with

this. this. The girls do not see their patterns and if we are to The girls do not see their patterns and if we are to help them, they have to be able to talk to us. We help them, they have to be able to talk to us. We need to help them answer the following questionsneed to help them answer the following questions

What are the feelings that trigger this?What are the feelings that trigger this? Are they feelings about you, about others, about your Are they feelings about you, about others, about your

world?world? What are the payoffs and benefits to you?What are the payoffs and benefits to you? What happens in your thoughts before you do this?What happens in your thoughts before you do this? When did you start, how did you learn about it?When did you start, how did you learn about it? What is your self harm history? (we are looking for What is your self harm history? (we are looking for

progression and loss of control)progression and loss of control)

Do others know and how have they Do others know and how have they responded?responded?

What do you think about this behavior?What do you think about this behavior? How do you feel during and after?How do you feel during and after? When don’t you self harm, what’s different When don’t you self harm, what’s different

about these times? What did you do to stop about these times? What did you do to stop yourself and can you use those things again?yourself and can you use those things again?

Are there any time patterns to your self Are there any time patterns to your self harming? Do these behaviors occur the same harming? Do these behaviors occur the same time every day, week, month, season, a point time every day, week, month, season, a point in your menstrual cycle?in your menstrual cycle?

Is this a reaction to trauma in your earlier Is this a reaction to trauma in your earlier life? Does the self harm patterns correlate life? Does the self harm patterns correlate with these past traumas?with these past traumas?

What is your ritual before, during after?What is your ritual before, during after?

How do you feel during the behavior; do you How do you feel during the behavior; do you like the pain, do you feel the pain, does it like the pain, do you feel the pain, does it clear your head, provide a release, change clear your head, provide a release, change your mood?your mood?

C.C. MOTIVATING CHANGE: MOTIVATING CHANGE: We Have To Help We Have To Help Them Find Some Motivation For ChangingThem Find Some Motivation For Changing

This Pattern Of BehaviorThis Pattern Of Behavior

How do you feel about yourself after the incident?How do you feel about yourself after the incident? How have others reacted to you?How have others reacted to you? What have you had to do to cover the scars and What have you had to do to cover the scars and

what has happened when you have been unable to what has happened when you have been unable to cover the scars?cover the scars?

What image do you have of your life after you are What image do you have of your life after you are free from this?free from this?

D.D. CLINICAL INTERVENTIONS: TeachingCLINICAL INTERVENTIONS: TeachingSkills For Overcoming Self Harm And Resolving Skills For Overcoming Self Harm And Resolving

Issues That Fuel Self Harming BehaviorIssues That Fuel Self Harming Behavior

If self harming is triggered by earlier If self harming is triggered by earlier trauma, we need to help the client recognize trauma, we need to help the client recognize the connection between past and present the connection between past and present feeling and self harming incidents. For feeling and self harming incidents. For many teens, talking about all their feelings many teens, talking about all their feelings about the original incident and about the original incident and understanding how it has impacted them is understanding how it has impacted them is the extent to their ability to resolve trauma the extent to their ability to resolve trauma directly.directly.

Adolescent females need to be taught to identify Adolescent females need to be taught to identify feelings. There is a difference between anger feelings. There is a difference between anger and anxiety. We need to help them label and and anxiety. We need to help them label and explainexplain

Adolescent females need to identify when their Adolescent females need to identify when their self harming is a way to communicate self harming is a way to communicate something to others. We need to help them something to others. We need to help them identify what message they are trying to send, identify what message they are trying to send, for whom it is intended, and a more productive for whom it is intended, and a more productive way to get their point acrossway to get their point across

Adolescent girls perceive that their feelings are Adolescent girls perceive that their feelings are unmanageable and they cannot tolerate them. unmanageable and they cannot tolerate them. We have to encourage them to view this We have to encourage them to view this differently, particularly since many girls self differently, particularly since many girls self harm to deal with feelings that are a normal harm to deal with feelings that are a normal part of the adolescent processpart of the adolescent process

Adolescent girls tend to think in terms of all or Adolescent girls tend to think in terms of all or nothing. They think in order to deal with nothing. They think in order to deal with unpleasant feelings, they have to be unpleasant feelings, they have to be extinguished entirely. In reality, they have to extinguished entirely. In reality, they have to lower their stress just enough to get it into the lower their stress just enough to get it into the range of tolerablerange of tolerable

A significant portion of the work we must do A significant portion of the work we must do with adolescent females involves changing with adolescent females involves changing scripts that do not serve them well. scripts that do not serve them well. Examples of scripts and changes that have to Examples of scripts and changes that have to occur with scripts include:occur with scripts include:

““I cannot stand it when someone is mad at me.”I cannot stand it when someone is mad at me.”

BECOMESBECOMES

““I can survive someone being mad at me.”I can survive someone being mad at me.”

““I am so bad I deserve to be punished.”I am so bad I deserve to be punished.”

BECOMESBECOMES

““I am not perfect but I do not deserve to be I am not perfect but I do not deserve to be punished.”punished.”

““I cannot handle my terrible feelings.”I cannot handle my terrible feelings.”BECOMESBECOMES

““My feelings are painful, but they will not My feelings are painful, but they will not last last forever.”forever.”

““I am not good enough.”I am not good enough.”BECOMESBECOMES

““I am good enough.”I am good enough.”

““I am not lovable.”I am not lovable.”BECOMESBECOMES

““I am lovable.”I am lovable.”

E.E. TEACHING BEHAVIORAL SKILLS TO TEACHING BEHAVIORAL SKILLS TO DISRUPT THE CYCLEDISRUPT THE CYCLE

Clear out objects that are instruments of self Clear out objects that are instruments of self harm.harm.

Develop a plan for sharing feelings when they Develop a plan for sharing feelings when they occur. This includes recognizing the start of a occur. This includes recognizing the start of a cycle and talking to someone before the cycle and talking to someone before the feelings escalate if possible.feelings escalate if possible.

Teach distraction techniques: finding an Teach distraction techniques: finding an activity that is incompatible with self harming, activity that is incompatible with self harming, leave the danger zone where self harming leave the danger zone where self harming usually occurs, engage the body and mind in usually occurs, engage the body and mind in an activity.an activity.

BEHAVIORAL SKILLS CONTINUEDBEHAVIORAL SKILLS CONTINUED

Teach teens how to clear their heads and distract Teach teens how to clear their heads and distract their thoughts: bumble bee breath, count their thoughts: bumble bee breath, count backwards from twenty, say the alphabet backwards from twenty, say the alphabet backwardsbackwards

Teach self soothing skills. Teach relaxation, Teach self soothing skills. Teach relaxation, anxiety reduction breath, calming rituals, anxiety reduction breath, calming rituals, moonbeams, musicmoonbeams, music

Teach them to break things down into manageable Teach them to break things down into manageable components (I just have to deal with the next five components (I just have to deal with the next five minutes)minutes)

BEHAVIOR SKILLS CONTINUEDBEHAVIOR SKILLS CONTINUED

Teach alternative discharge of hand energy (worry Teach alternative discharge of hand energy (worry stones, koosh balls)stones, koosh balls)

Recognizing triggers. Classify triggers into two Recognizing triggers. Classify triggers into two categories: ones that can be avoided (avoid these), categories: ones that can be avoided (avoid these), ones that can’t be avoided (come up with a plan to ones that can’t be avoided (come up with a plan to deal with these)deal with these)

F.F. CONSIDER REFERRAL FOR CONSIDER REFERRAL FOR MEDICATIONMEDICATION

AntidepressantsAntidepressants

Mood stabilizersMood stabilizers

Anti-anxiety medicationAnti-anxiety medication

G.G. WORK ON BOUNDARY ISSUESWORK ON BOUNDARY ISSUES

Self Over OthersSelf Over Others

Others Over SelfOthers Over Self

ExternalExternal

InternalInternal

Parents As Part of The SolutionParents As Part of The Solution

* Assist them understanding and processing* Assist them understanding and processing

own reactionown reaction

* Understanding what it means for their child * Understanding what it means for their child and child’s triggers and child’s triggers

* Discuss appropriate* Discuss appropriate

- responses- responses

- monitoring- monitoring

- limits- limits

- consequences- consequences

- communication- communication

* Develop plan for support* Develop plan for support