1. Self-Injurious Behavior in Adolescents WJCIA Annual Training Conference Stevens Point September 28, 2007

2. Kay F. Heimerl, MS LCSW Outagamie County DHHS heimerkf@co.outagamie.wi.us (920)832-5270

3. Self Injurious Behavior How will you know I’m hurting If you cannot see my pain? To wear it on my body Tells what words cannot explain. - C. Blount

4. Definition: An injury to one’s own body, done without suicidal intent or intent to attain sexual gratification. Self-inflicted harm is enough to cause tissue damage. Not part of spiritual ritual or for ornamental purposes. Done as a way to alter a perceived intolerable mood state.

5. Demographics 3 million Americans 1% of the general population Males and Females Middle class and educated History of abuse and/or trauma Often starts in early teens, peaks from ages 18-24, decreases in 30’s and 40’s

6. Methods of SIB Cutting Burning Scratching Picking Interfering with wound healing Head banging Hitting self

7. Methods of SIB cont… Breaking bones Hair pulling Spooning Eating harmful objects – lightbulbs, glass, plastic Ingesting chemicals Over/under eating

8. Comorbid behaviors Reckless driving Unprotected sex Shoplifting Promiscuity Substance abuse Eating disordered behavior

9. Wound Severity Extent of the damage Level of medical intervention required Location of the wound

10. High Risk Groups Emotionally disturbed children History of trauma/abuse Borderline Personality Disorder Young males with psychosis Gender identity disorders Dissociative disorders

11. High Risk Groups cont… Substance abusers Teens whose parents are physically or emotionally unavailable to them Teens with untreated depression or anxiety

12. Why do people self injure?.

13. Because it works!!! All self-injury is designed to feel good at that moment.

14. Purpose of SIB Relief from psychological pain Release of tension Affect regulation – can’t feel, feel too much Communicate feelings – anger, sadness, pain, etc.

15. Purpose of SIB cont… Way of being in control Defense mechanism Feel the need to be punished To be unattractive Endorphins of physical pain cover up the emotional pain “Event marker”

16. Attention seeking??? Not usually Sometimes done to induce rescuing behaviors in others Can provide an opportunity for self-care afterwards

17. Attention Seeking??? Actually it is often under-diagnosed and under-reported due to: Shame, guilt, fear, pride Learned distrust of others Fear of legal consequences Mixed feelings about treatment/recovery

18. SIB is often preceded by one or more of these emotional factors: Depression Stress Hopelessness Powerlessness Purposelessness Anxiety Fear

19. Psychological characteristics of Self Injurers Invalidate self Hypersensitive to rejection Pervasive anger Tend to suppress anger Impulsive High levels of aggressive feelings Act on immediate mood

20. Psychological characteristics cont... Feel powerless over how or whether they cope with life Not future-focused Depressed/suicidal/self-destructive Anxious Lack of coping skills Avoidant

21. How should we react? Don’t ignore it! Always take it seriously. Don’t judge! Show concern. Stay calm and sincere. Don’t overreact, rescue or “hyper- nurture”.

22. How should we react? Remember that it is a cry for help. Find out what is going on beneath the behavior. Listen! Listen! Listen! Don’t punish! Any interventions should be designed to protect, not to punish. Acknowledge the SIB as a survival strategy.

23. How should we react? Assess the extent of the injury and intervene appropriately. Let them know that it is OK to talk about their SIB. State that you cannot talk to the person while they are injuring because you care about them and it hurts you to see that.

24. How should we react? Do not use ultimatums – i.e. stop or else! Set reasonable limits.

25. Interventions/Referrals: You must find something to replace the behavior. You can’t just take it away.

26. Interventions/Referrals: Psychotherapy – many methods and interventions Trauma work – therapy, PTSD Workbook, EMDR Contracts – agree to try alternate behaviors before SIB Alternate behaviors need to be harm reducing – rubberband snapping, hands in ice, chewing cinnamon or hot peppers, etc.

27. Interventions/Referrals: Medication Develop Personal Validation Spirituality Meditation Yoga, Tai Chi Appropriate physical releases

28. Interventions/Referrals: Group therapy – DBT, Abuse survivors Family therapy Change core beliefs and values Teach emotional literacy – feeling lists, journaling Safety bag

29. Safety Planning Assessment questions Do you need to hurt yourself? What has brought you to this point? Have you been at this point before? What did you do then to deal with it? How did you feel then? What have you done to ease this discomfort in the past? What else can you do that won’t hurt you?

30. Safety Planning Assessment questions cont… How do you feel right now? How do you feel after hurting yourself? How will you feel tomorrow morning? Can you avoid this stressor, or deal with it better in the future?

31. Safety Planning Contracts List alternate behaviors to use before SIB Names and numbers of contact persons When to call Crisis When to seek medical attention Discuss placement options ahead of time if possible – i.e. hospital, crisis bed, secure detention, family member, etc.

32. Safety Planning Decide who will be included in the contract – parents, school personnel, mentor, physician, etc. Determine length of contract viability Be clear about mandatory reporting obligations and potential consequences Consult with Mental Health professional

33. QUESTIONS???