Self injury behaviour - ab

SELF-INJURY BEHAVIOUR IN YOUTH:

ISSUES AND STRATEGIES

Self-injury can be difficult for loved ones and people in the helping field to understand. This workshop will assist participants in understanding the experience and motivations of adolescents who intentionally injure themselves. In addition, the course will provide practical strategies for working with youth struggling with this complex issue. Participants will leave this workshop with increased insight regarding self-injury behaviour in youth and direction for effective interventions.

This training material was developed by Kimberly R.W. Enns, MSW, RSW, Trainer and Consultant with CTRI Inc.

Self-Injury Behaviour in Youth: Issues and Strategies © 2010 CTRI Crisis & Trauma Resource Institute Inc. & Kimberly R.W. Enns, MSW, RSW

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of CTRI Crisis & Trauma Resource Institute Inc.

Disclaimer All information provided in or throughout this course, manuals and/or training is for educational and informational purposes only. It is not intended to provide individual counselling or advice and should not be relied upon for such purposes. You should assess whether you require additional information and, where appropriate, seek independent professional advice. Although Kimberly R.W. Enns, MSW, RSW and the Crisis & Trauma Resource Institute Inc. believe that the information is accurate and reliable when it is presented, we do not guarantee that the information will always be accurate or current. We and any of our employees, directors, shareholders, officers, agents, affiliates, licensors or suppliers are not legally liable to any person for damages arising out of or related to the use or application of the contents of this course, manual, and/or training and the information contained within them. You agree at all times to indemnify, defend and hold harmless us of all actions, proceedings, costs, claims, damages, demands, liabilities and expenses whatsoever (including legal and other fees and disbursements) sustained, incurred or paid by us directly or indirectly in respect of the use or application of the contents of this course, manual, and/or training and the information.

© CTRI Crisis & Trauma Resource Institute Inc. 2

DEFINITIONS

Self-Injury: Self-injury is deliberate, self-effected bodily harm of a socially unacceptable nature, done without suicidal intent and carried out to reduce psychological distress.

Deliberate: _______________________________________________________

Self-effected: _____________________________________________________

Bodily harm: ______________________________________________________

Socially unacceptable: ______________________________________________

Without suicidal intent: ______________________________________________

Reduces psychological distress: ______________________________________

Common Terms: Problematic Terms: Self-harm Self-mutilation Self-injury Suicidal gesture Non-suicidal self-injury Para-suicide behaviour Body Modification:

Permanent or semi-permanent altering of the body for non-medical reasons.

Includes professional tattoos, body piercings, brandings, scarification, plastic surgery.

Distinguished from self-injury because the tissue damage is viewed as symbolically meaningful, beauty enhancing, as a form of self-expression or done for religious or cultural reasons.

Generally not about reducing emotional distress.

Widely accepted in many social contexts.


CATEGORIES OF SELF-INJURY BEHAVIOURS

DIRECT SELF-INJURY Armando Favazza (1998) developed the following system of categorizing direct self-injury:

Stereotypic Self-Injury

Repetitive, rhythmic, monotonous, self-stimulating behaviours (head-banging, skin-picking, self-biting).

Often a result of a biological/sensory drive without particular emotional meaning.

Usually associated with a specific syndrome diagnosed in infancy or early childhood (Autism, Tourette Syndrome).

Major Self-Injury

Dramatic acts that cause significant tissue damage (amputation, castration, bone breaking, eye removal).

Rare, tends to be a single, isolated event.

Occurs most often when a person is not in touch with reality (drug-induced or psychotic state, i.e., schizophrenia).

Compulsive Self-Injury

Repetitive, compulsive, habit-driven behaviours (hair-pulling, skin-picking, nail-biting, obsessive hand-washing).

May not be under a person’s conscious control.

Usually associated with obsessive-compulsive disorder, trichotillomania, body dysmorphic disorder.

Only considered to be a disorder if the behaviour interferes with the person’s ability to participate in life on a daily basis.

Impulsive Self-Injury (Common Self-Injury)

Direct, intentional, intent is unambiguous.

Psychologically motivated (i.e., as a means to cope with emotional pain).

Common self-injury includes but is not limited to:

Scratching Interfering with wound healing Cutting Carving Burning Hitting


INDIRECT SELF-INJURY With indirect self-injury the harm is accumulative; there is generally not immediate tissue damage. There is a tendency for individuals to deny any harmful impacts as some behaviours may be culturally sanctioned (smoking, drinking, over-eating) . Substance Misuse

Alcohol misuse

Illicit drug use

Use of inhalants

Eating Disordered Behaviour

Anorexia

Bulimia

Binge-eating

Risk-Taking Behaviour

Physical

Sexual

Situational

COMPONENTS OF ALL SELF-INJURY BEHAVIOURS

Direct or indirect: How intentional is the self-injury?

Lethality: How likely is death in the near future as a result of the self-injury?

Repetition: Is the act done once or repeated frequently over a period of time?

Multiple episodes (frequent drug overdose)

High lethality Single episode (jumping from a height)

Direct Multiple episodes (common self-injury i.e., cutting)

Low lethality Single episode (self-inflicted burn)

Multiple episodes (advanced anorexia)

High lethality Single episode (drinking and driving)

Indirect Multiple episodes (smoking, drinking alcohol)

Low lethality Single episode (refusal of medication)

CATEGORIES OF SELF-INJURY BEHAVIOURS


DISTINGUISHING SUICIDE ATTEMPTS FROM SELF-INJURY

There is often an assumption that self-injury is a suicide attempt. It is important to understand that common self-injury is rarely about taking one’s life, but over time can become a risk factor for suicide. Some comparisons follow:

SUICIDE ATTEMPT

SELF-INJURY

Intent is to end all feeling; escape life

Intent is to feel better by obtaining relief from intense emotions or from numbness

Serious physical damage, lethal means used

Modest physical damage, non-lethal means used

Rarely chronic, one method used

Frequently chronic, several methods used over time

Sense of hopelessness and helplessness; suicide is seen as the only way out

Some sense of control: there is an option for managing emotions

No decrease in discomfort following the act

Rapid decrease in discomfort and return to usual affect

Central issue: Depression/rage/grief regarding inescapable pain (Adapted from Walsh, 2006)

Central issue: a) Body alienation/numbness or b) Emotional vulnerability, inadequate self-soothing skills, peer influences that endorse self-injury

Cautionary Notes:

Studies indicate that many individuals engage in self-injury as well as suicide attempts at some point in their lives (Nixon & Heath, Eds. 2009).

Self-injury is considered a risk factor for suicide.

Damage from self-injury may escalate as a person needs more to obtain the same effect.

Damage can be more serious than intended, such as cutting into an artery and being unable to stop the bleeding.

Suicide risk assessment is important.


WHAT CAUSES SELF-INJURY?

The definitive causes of self-injury have not been pinpointed, though researchers agree that biology, personality and childhood environment all play a role. BIOLOGY Serotonin Theory:

Serotonin is a neurotransmitter that regulates mood, aggression, temperature, appetite, sleep and sex drive.

Some research indicates that people who self-injure may have less serotonin activity than people who don’t self-injure.

Low serotonin activity is associated with negative mood, anxiety, diminished impulse control and aggression to self.

Opiate/Endorphin Theory:

Opiates/endorphins are neurotransmitters related to pain relief and feelings of well-being.

One theory is that people who self-injure have overly active opioid systems and experience a large burst of opioid activity when they are injured.

This results in significant pleasure/relief from self-injury as well as above average pain tolerance.

PERSONALITY

Some research suggests that certain personality traits predispose people to self-injure.

Impulsivity: difficulty delaying gratification.

Neuroticism: the tendency to experience strong, negative emotions.

Perfectionistic tendencies.


CHILDHOOD ENVIRONMENT

Approximately 50% of individuals who self-injure were abused as children (Gratz & Chapman, 2009).

An invalidating environment (child’s emotional experiences are disregarded) can make one more vulnerable to self-injury.

Poor emotional connection or bond with caregivers.

Harsh punishment (may self-injure in order to continue punishing self).

BIOSOCIAL THEORY (Linehan, 1993)

Emotion dysregulation is viewed as the result of both one’s disposition and the environment in which one exists.

Emotional vulnerability refers to being highly sensitive and reactive with poor ability to modulate the resulting strong emotions.

An invalidating environment fails to teach a child to trust and learn to modulate his or her own emotional experiences.

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Risk Factors

Self-injury behaviour in one’s family or peer group

Symptoms of depression and/or anxiety

Low self-esteem

Emotion dysregulation

Problems with substance abuse and/or eating disorders

Adverse childhood environment

Protective Factors

Effective management of negative emotions

Family and social support (Nixon & Heath, Eds. 2009)

WHAT CAUSES SELF-INJURY


INCREASED PREVALENCE OF SELF-INJURY

There seems to be solid evidence that self-injury is not merely becoming more visible but actually more prevalent. Many have speculated as to the social influences that may speak to the increase: Family Breakdown

Rise in divorce rates and single parent families.

Children/adolescents are spending more time alone - parents may not be available for emotional support or to teach self-soothing skills.

Youth are subsequently receiving more information regarding emotion regulation from each other.

Community/Cultural Breakdown

Loss of connection: people and relationships are transient.

Extended community (family, friends, neighbours) not as available to support one another.

Loss of cultural and traditional values, knowledge, language. Pressure to Excel

Pressure to outperform peers in academics, athletics, etc.

Busy, highly stressful lifestyles, pressure to ”do it all.”

Alternatively, some families cannot afford to enrol their children in extra-curricular activities, or the community has limited options.

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Technology

Mobile phones, texting, instant messaging and social networking sites (Facebook, Twitter, Myspace, etc.) have dramatically altered the way people interact.

Many adolescents have a mobile phone, TV, MP3 player, laptop or tablet, which may serve to decrease face to face contact with others.

Healthy development of emotion regulation skills is being impacted by technology. Media Influences

Emphasis on products/medication to achieve desired mood (no need to tolerate any discomfort, outside agent is readily available).

Many websites, chat rooms, television shows, movies and music videos feature or even promote self-injury.

People prominent in the media report self-injuring (i.e., Angelina Jolie, Johnny Depp, Marilyn Manson).

Body Image and Sexuality

Intimate relationships are being entered into at an earlier age.

May result in pressure and emotional intensity for which youth are not ready.

Young people are exposed to unattainable body ideals; can lead to obsession with physical appearance and self-loathing when ideals cannot be met.

Peer Influences

Adolescents may seek refuge in a peer group that engages in, admires and thereby reinforces self-injury.

Youth may wear their self-injury scars as badges of honour representing suffering, tolerance of pain or bravery.

Those who self-injure tend to cluster together as there is mutual understanding and reduced fear of rejection.

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INCREASED PREVALENCE OF SELF-INJURY


FUNCTIONS OF SELF-INJURY

Below are some of the most common reasons people give for harming themselves.

To Feel Better

Many individuals report feeling rapid relief from emotional distress upon engaging in self-injury.

The physical pain of self-injury may be a distraction from emotional pain.

For some, an extreme action like self-injury seems to be the best way to express an intense emotional experience.

Self-injury may be a means of releasing built-up emotions. To Get a Rush

Self-injury causes endorphins to be secreted into the bloodstream.

For some individuals, this produces a natural high or a rush that can be invigorating and addictive.

To End Dissociation or Emotional Numbness

Dissociation refers to feeling disconnected from the present moment, one’s body or one`s surroundings.

Dissociation is sometimes self-preserving as it can allow one to temporarily avoid or escape emotional pain, but it can also become automatic and uncomfortable.

Self-injury may be used as a means of relieving this state and reconnecting to the present moment.

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To Punish Oneself

Some individuals come from environments in which messages of worthlessness are constantly received. Self-injury may be an expression of self-loathing.

Other people express feelings of intense guilt and shame; they may blame themselves for problems or past trauma.

Self-punishment through self-injury may absolve one of some of these feelings or be viewed as a form of repentance from sin.

To Communicate to Others

Those who self-injure may have difficulty opening up to others or may feel invalidated when they try to do so.

Self-injury communicates the extent of one’s emotional pain without the need to use language – may be a cry for help.

Important not to dismiss as attention-seeking or manipulative behaviour. ______________________________________________________________________

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How does an individual start self-injuring?

Often begins on an impulse.

May start because of others in life who are self-injuring.

May learn about self-injury through TV shows, movies, music videos, chat rooms.

In some cases may be accidental: injury occurs and the individual feels surprisingly soothed.

Extreme agitation/rage often results in a desire to respond physically – pattern of self-soothing through aggressive acts may develop.

FUNCTIONS OF SELF-INJURY


PROBLEMATIC REACTIONS

Caregivers, upon discovering that a young person is self-injuring, may understandably become anxious and fearful for that person’s safety. Extreme reactions as well as choosing to ignore the behaviour may serve to trigger or maintain the self-injury.

Reaction may be one of anger (i.e., lectures) or disgust (i.e., recoil).

The self-injury may be considered “just attention seeking” or a form of manipulation and therefore ignored.

Behaviour is assumed to be suicidal and youth is placed on suicide watch.

Caregiver issues ultimatums.

Youth’s bedroom and belongings are regularly searched for self-injuring tools.

Caregiver worries that every word or action may prompt a self-injuring incident.

Caregiver does not respond at all to the behaviour due to personal discomfort.

Behaviour is viewed as a phase that will disappear on its own.

Caregiver’s primary concern is with how the self-injury reflects on them.

Why it is Important to Respond:

Some young people use destructive behaviours in an attempt to create relationship, or involvement from adults; may have learned that the only way to gain this involvement is through being in crisis.

Some individuals display their injuries/make no attempt to hide them: likely putting pain on display in the hopes that someone will notice there is a problem.

Self-injury is the perfect vehicle to express the need for help without ever having to approach anyone about it.

When consistently ignored, self-injury is likely to escalate so that there is no possibility of anyone ignoring it.

Early detection and intervention is critical.


SELF-INJURY WARNING SIGNS

Individuals who self-injure are often very good at hiding it from others. They may feel shame and fear judgemental reactions. Sometimes a self-injurer will recognize that they have a serious problem and seek help, but more often parents/caregivers/friends will detect that something is wrong. Warning Signs

Frequent injuries (i.e., cuts, bruises, burns) with suspicious explanations.

Wearing pants and long sleeves in warm weather (to cover injuries).

Wearing bangles, bracelets and wristbands (to cover injuries).

Low self-esteem.

Difficulty handling emotions, easily overwhelmed.

Extremely sensitive to rejection.

Self-defeating comments and attitude.

Extreme emotional ups and downs (due to the cycle of self-injury).

Difficulty functioning at school, work or home.

Relationship problems.

Avoiding sports or other activities that would require showing more of one’s body.

The presence of behaviours that often accompany self-injury: eating disorders, drug/alcohol misuse, excessive risk-taking.

Discovery of tools used for self-injury (broken disposable razors, lighters, un-bent paper clips).

Bloodied wads of tissue or toilet paper, blood on towels or clothing.

First aid supplies being used quickly.

Rubbing arms, especially wrists, through sleeves (cuts often itch while they are healing).

Withdrawing from activities once enjoyed.

Increased time alone

Increased time with peers who self-injure.


THE CYCLE OF SELF-INJURY

(Adapted from Sutton, 2005)

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Trigger

- i.e., Interpersonal conflict, social isolation, academic

demands, etc.

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- self-defeating thoughts

Escalating Emotional Tension

- Distorted, negative thinking occurs, leading to

overwhelming emotions

- Individual starts to feel agitated/ready to explode

Panic

- Individual experiences an irresistible urge to self-injure

Self-Injury

- Severe tension is rapidly reduced

- Individual may or may not feel pain during act

Return to Normalcy

- Sense of calm and relief/ feeling more alive and better

able to function

Reaction

- Initial calm and euphoria replaced with feelings of

shame or guilt

- Communication with others may occur


INITIAL RESPONSE

The strategies outlined in this manual follow the principles of cognitive behaviour therapy and dialectical behaviour therapy, common approaches for working with self-injuring adolescents. Successful intervention often involves active participation from the family, the individual’s social network and professionals from the larger system. The initial response to an individual regarding their self-injuring behaviour can have significant long-term effects. As self-injury behaviour runs counter to human expectations regarding self-protection, normal reactions may include fear, recoil, shock, anger and hysteria. These reactions may prevent an individual from seeking help. Others may respond with an outpouring of empathy, which may inadvertently reinforce the behaviour. When working with individuals who self-injure:

Do not dismiss or minimize the self-injury.

Validate the individual regarding the intense emotions that have led to self-injury.

Avoid reactions of judgement, recoil or shock.

Avoid dramatic outpourings of concern and support.

Calmly assist in obtaining medical attention if necessary.

Do not insist on immediate abstinence from self-injury.

Manner should be matter-of-fact, calm and compassionate.

Convey the message that many have overcome self-injury and they can too.

Remember that a strong therapeutic alliance is critical to the process of overcoming self-injury.

Be cognizant of the individual’s readiness for change. (Appendix p.51) ______________________________________________________________________

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SELF-INJURY CONTAGION

Self-injury contagion refers to a statistically significant cluster of self-injury behaviour occurring within a group. Studies have shown that self-injury contagion is particularly prevalent amongst adolescents. There is a rising trend for youth to discuss self-injury online and to form cutting clubs within their schools, thereby triggering the behaviour in each other. In some cases, youth self-injure in one another’s presence, may share tools or even take turns injuring one another. Why Does Contagion Occur?

Many youth are introduced to self-injury through a friend.

Self-injury may produce feelings of cohesiveness within a group.

Self-injury may be encouraged, admired and thereby reinforced within a social context.

Self-injury is a powerful form of communication.

The behaviour may be inadvertently reinforced by the adult response. Preventing / Responding to Contagion

Reduce communication regarding self-injury among members of a peer group: Adolescents may compete with each other regarding the extent of self-injury. Some youth post pictures and vivid descriptions regarding their self-injury online.

Reduce the display of recent self-injury wounds by requiring that appropriate, covering clothing be worn.

Caregivers must strive to react to self-injury behaviour in a calm manner, recognizing the seriousness of the issue but not inadvertently increasing its appeal through reactions of hysteria or an outpouring of empathy.

Within a given community, self-injury should generally be treated through individualized methods, rather than in groups.


RESOURCES

LITERATURE Barnett Veague, H. (2008). Cutting and self-harm. New York, NY: Chelsea House Publishers.

Beck, J.S. (1995). Cognitive therapy, basics and beyond. New York, NY: Guilford Press.

Bowman, S., Randall, K. (2006). See my pain! Creative strategies and activities for helping young people who self-injure. Chapin, SC: YouthLight, Inc.

Conterio, K., Kingson Bloom, J. & Lader, W. (1998). Bodily harm: The breakthrough healing program for self-injurers. New York, NY: Hyperion Press.

Gratz, K.L. & Chapman, A.L. (2009). Freedom from self-harm: Overcoming self-injury with skills from DBT and other treatments. Oakland, CA: New Harbinger Publications, Inc.

Hardy, K.V. & Laszloffy, T.A. (2005). Teens who hurt: Clinical interventions to break the cycle of adolescent violence. New York, NY: The Guilford Press.

Hollander, M. (2008). Helping teens who cut. New York, NY: The Guilford Press.

Kabat-Zinn, J. (2007). Mindfulness for beginners. Louisville, CO: Sounds True, Inc.

Kettlewell, C. (1999). Skin game: A cutter’s memoir. New York, NY: St. Martin’s Press.

Leatham, V. (2006). Bloodletting: A memoir of secrets, self-harm and survival. Oakland, CA: New Harbinger Publications, Inc.

Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press.

Walsh, B.W. (2005). Treating self-injury: A practical guide. New York, NY: The Guilford Press.

RECOMMENDED FORUMS FOR SELF-INJURERS

The following forums are carefully moderated for triggering content and any form of self-harm promotion. Their focus is to support individuals in their journey towards healing and wellness.

www.dailystrength.org www.recoveryourlife.com

www.selfinjury.com/blog/ Yahoo groups: Nofear-SAFE_approved

http://www.dailystrength.org/

http://www.recoveryourlife.com/

http://www.selfinjury.com/blog/


PHONE –DISTRESS LINES Alberta HealthLink 1-866-408 5465 Saskatchewan Healthline 1-877-800-0002 Manitoba Healthlinks 1-888-315 9257 Nunavut Kamatsiaqtut Help Line (800) 265 3333 Yukon Mental Health Services (867) 667 8346 NWT Mental Health and Addiction Services Specialist (867) 873 7033 NWT Helpline 1-800-661 0844 (7-11 pm) Information, Support, and Referral National Kids Help Phone 1-800-668-6868 1-800-DONT-CUT WEBSITES

Lifesigns: Self Injury Guidance and Network Support: www.lifesigns.org.uk

Public Health Agency of Canada: www.canadian-health-network.ca

S.A.F.E. (Self-Abuse Finally Ends) Alternatives: www.selfinjury.com

Self-Injury: www.mirror-mirror.org/selfinj.htm

Self-Injury and Related Issues: www.siari.co.uk

Suicide and Mental Health Association International: www.suicideandmentalhealthassociationinternational.org

Secret Shame: Self-Injury Information and Support: crystal.palace.net/~llama/psych/

Youth Noise: www.youthnoise.com

FirstSigns Voluntary Organisation: www.selfinjury.org.uk/

http://www.canadian-health-network.ca/

http://www.mirror-mirror.org/selfinj.htm

http://www.suicideandmentalhealthassociationinternational.org/

http://www.youthnoise.com/

Self injury behaviour - ab

Health & Medicine

Transcript of Self injury behaviour - ab