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Adolescent Non-Suicidal Self Injury
 
Non-suicidal self injury consists of a broad range of behaviors defined as direct, deliberate, and socially unacceptable destruction of one's own body tissue without intent to die. These include skin cutting, burning, picking or interfering with wound healing, punching oneself or objects and more. There is a wide variation of frequency and methods. NSSI appears to be increasing and many professionals feel ill-equipped to handle this behavior. It is estimated that 12-40% of adolescents have engaged in self injurious behaivors. Often an adolescent will learn about "cutting" from a friend or a peer at school or through the media. The majority of self injuring adolescents engage in NSSI with little thought, while sober and report experiencing little to no pain while self injuring and typically begins between 12 and 14 years of age. A concern for those who work with adolescents is that of "social contagion" or the spread of self-injurious behavior through the media, including movies, books, music, and the Internet. There are ways in which the media could be used to reduce the influence as well.
 
Self Injurous Behavior is currently in the DSM IV only as a symptom of borderline personality disorder, however current research is showing that it may occur with psychiatric disorders such as depressive or anxiety disorders, substance abuse, eating disorders and conduct or oppositional disorders. Self injury has a complex relationship with suicidal behavior. There are differences between self injury and suicide. 
 
 
Motivations to self injure can be seen as a way to seek release from internal emotions such as to stop bad feelings, to relieve feeling numb, to feel something, to punish themselves or to feel relaxed. However it also may be used to regulate the external environment, as a way to get attention, to feel part of a group, to get control, to let others know they are desperate, to get help, to avoid being with people, to get parents' attention or reaction, or to make others angry, etc.
 
Here are some guidelines when first responding to students engaging in NSSI:
Approach the student in a calm and caring way.
Accept him/her even if you don't accept the behavior.
Understand that this is a way of coping with the pain they feel inside.
Show a willingness to listen and compassion with non-judgment.
Avoid over reacting. Don't respond with panic, shock or revulsion.
Don't try to stop the behavior with threats.
Don't show excessive interest in the SI.
Don't allow the student to relive the experiences of SI in detail as it may be triggering.
Don't talk about it in front of the class. 
 
At this time few prevention or intervention approaches targeting NSSI have been developed and empirically supported. According to Nixon (2009) the following hold promise: psycho-education,concerning mental health and NSSI, problem solving therapy and crisis intervention, cognitive behavioral therapy and dialectical behavior therapy. Teaching adolescents healthy coping strategies to deal with emotions, as well as breaking down barriers and stigma in seeking mental health services are important.  Web resources: S.A.F.E. Alternatives (www.selfinjury.com) Free resources and articles. Self Injurious Behavior Webcast: www.albany.edu/sph/coned/t2binjurious.htm) video interview with Director of Cornell Research Program on SI is well produced and informative. Approved for CEU's  for the hour long webcast.
 
(adapted from The Prevention Researcher, Volume 17, Number 1, February 2010: Adolescent Self-Injury) I highly recommend subscribing to The Prevention Researcher as it is a wonderful source of information regarding youth issues today and how we can best support them. 

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Assisting Students at Risk for and Engaging in Self Injurious Behavior:

 

Currently there are few proven prevention or intervention methods for reducing suicidal and non-suicidal SIBs. Some evidence points to the fact that Cognitive Behavioral Therapy and problem solving treatment approaches are effective. Most school counselors report feeling unprepared or underprepared to deal with SIB. Many claim that the support they offer at school comes more from their own professional experience plus intuition vs relying on evidence based or well documented school counseling activities and services. SIB is obviously a dangerous condition and is beyond the scope of the school counselors general practice and must be referred to a highly trained therapist. 

 

Prevention:

 

1. Start Early:  beginning with early elementary school children and later reinforced in secondary students, counselor educational activities should address the development of emotion regulation (ER) skills. This may well serve to prevent later emotional disorders such as SIB.

2. Teach fundamental emotional regulation skills.  Because ER (emotional regulation) is closely linked with emerging healthy psychosocial functioning as well as early academic success (Graziano, Reavis, Keane and Calkins, 2007), students need to learn effective strategies to identify and manage their levels of stress and emotionality. In particular, classroom guidance and small groups should address with students how to manage and cope more productively with increasing levels of arousal, anxiety and confusing emotions.

 3. Strengthen educator -student relationships: Elementary and secondary school counselors need to work closely with educators to enhance the student teacher relationships. Evidence suggests that students with better ER skills have more positive and caring relationships with educators and exhibit fewer behavioral problems. In other words the quality of the student-teacher relationship seems to mediate the relation between children's ER skills and academic achievement.

 

4. Screen: As seen with depression and anxiety, screening for SIB may be developed in consultation with outside mental health experts. 

 

Intervention:

 

Notification:

1. If SIB was discovered at school, with ethical and legal considerations in mind, the school counselor notifies all relevant parties (administrator, school nurse, parent/guardian).

2. Consultation and referral: Then with all appropriate people, a referral is made that day to a mental health professional, who has extensive experience with students with SIB. Depending upon the severity of the wounds, a physician may also be contracted. Diagnosis and prognosis are left to trained mental health professionals. It helps when determination of the student showing signs of non-suicidal self injury or suicidal self injury is shared with the school counselor, so that appropriate care and follow up can happen. Make sure that the outside professional has written consent from parents or guardians to regularly connect with the school counselor.

3. Collaboration: Team up with the mental health professionals, family and school nurse as well as relevant educators to provide an accommodating and safe school environment. Teachers have often significant influence on students who engage in SIB the teacher-student interaction patterns should be "monitored". It is important that classroom academic and behavioral expectations are set and maintained. The school counselor can act as a coordinator of support services, working to create school environments where self injury is more likely to be identified early on by school staff, students, and parents and students in early stages of SIB will receive outside counseling sooner. An action plan is devised with the help of the school counselor which helps when a student returns to school following any type of in-patient treatment facility. Until the student is in a solid stage of recovery, school personnel should try to minimize stressful experiences. 

4. Follow up meetings: Periodic "check ins" with students and families are recommended. With family and student authorization, continue to provide support to other educators (teachers,coaches) on how to best assist the student. Follow up on the plan and modify it if necessary. Assuming the students continues with outpatient therapy while attending classes, consult with the outside professional to determine if additional support services are needed.

5. Individual supportive counseling: Several counseling skills, when meeting one on one, have been found to be most supportive: respectful attending, empathic understanding, and acting as a friend, which means establishing a positive personal connection with the student. What doesn't work and can be harmful is to show a lack of care and/or to force views on clients. 

 

Resources: Self Injurious Behavior

 

http://www.selfinjury.com     Great resource on self injury and has a lot of info and a video for parents who have children who are engaging in SI

 

Walsh, B.W. (2008) Treating Self Injury: A Practical Guide

American Academy of Child and Adolescent Psychiatry:  www.aacap.org/page.ww?name=Self-Injury+In+Adolescents&section=Facts+for=Families

American Association for Marriage and Family Therapy,  www.aamft.org/families/Consumer_updates/Adolescent_Self_Harm.asp

 

American Self Harm Clearinghouse,  www.selfinjury.org/

Helpguide.org, www.helpguide.org/mental/self_injury.htm

S.A.F.E. Alternatives, http://www.safe-alternatives.com/

Self-Injury and Related Issues, www.siari.co.uk/

 

Self-Injury Information and Support:  www.psyke.org

 

Self Injury: A Struggle, http://self-injury.net/

 

Books on the subject

Helping Teens Who Cut: Understanding and Ending Self-Injury (Paperback)

~by  Michael Hollander PhD  (2008)
 

See My Pain! Creative Strategies and Activities for Helping Young People Who Self-Injure (Paperback)

~ Susan Bowman (Author), Kaye Randall (Author)
 

Treating Self-Injury: A Practical Guide (Paperback)

~ Barent W. Walsh PhD (Author)  (working with self injurers since the 1970's)

 

Mental Health Interventions for School Counselors by Christopher Sink (2011 Brookes/Cole)

Stopping the Pain: A Workbook for teens who cut and self injure by Lawrence Shapiro, PH.D

 

Excerpt from an interview with Berent Walsh, expert in self injurious behavior since the 1970's

(to read the complete interview click below on the hyperlink)

 

Because self-injury spreads through social contagion (e.g., by word of mouth, from peer to peer), it is important that clinicians who are trying to treat self-injury take care when providing group therapy. Primarily, it is important to limit the telling of details about self-injury and "war stories", and to focus the group's efforts on the learning of healthy methods of coping with strong painful emotions that can become a real alternative to self-injury. It is important that clinicians, parents and caregivers respond to self-injury with a "low-key, dispassionate demeanor", meaning that such authority figures not freak out or make a big deal out of the self-injury, or panic and lock someone up for suicidal tendencies, or become too solicitous and in so doing, reinforce the relationship between self-injury and attention. Dr. Walsh encourages clinicians to present a "respectful curiosity" about the function of the self-injury for each patient, meaning that it is useful to ask each patient why they are self-injuring - what self-injury does for them. Asking about the function of the self-injury helps both parties to understand the self-injury as a (dysfunctional) coping strategy, and helps encourage rapport.

Dr. Van Nuys asks Dr. Walsh about various ways clinicians should respond to particular types of self-injury. Dr. Walsh suggests that a crisis response, including hospitalization is appropriate for self-injuries that are significant enough as to require medical attention (such as sutures), and those self-injuries which are inflicted upon the face, eyes, breasts or genitals. These later self-injuries to facial and genital areas are frequently associated with psychosis, or with post-traumatic stress secondary to significant abuse or torture. For lessor forms of self-injury a crisis response would be counter-productive.

The primary form of treatment that is useful for clinicians to offer self-injurers involves replacement skills training, e.g., the teaching of healthy coping skills for managing emotions. Dr. Walsh suggests that the cognitive behavioral approach is frequently useful. It is not useful that authority figures demand that patients stop self-injuring or forbid it from occurring. Instead, it is useful to teach alternatives to self-injury and let patients stop self-injuring at their own pace. Patients have become very dependent on self-injury as a means of managing their moods and it is hard for them to give it up.

Interview with Berent Walsh, expert on Self Injury

For Self Injurers: How do I know if I'm ready to stop?

Deciding to stop self-injury is a very personal decision. You may have to consider it for a long time before you decide that you're ready to commit to a life without scars and bruises. Don't be discouraged if you conclude the time isn't right for you to stop yet; you can still exert more control over your self-injury by choosing when and how much you harm yourself, by setting limits for your self-harm, and by taking responsibility for it. If you choose to do this, you should take care to remain safe when harming yourself: don't share cutting implements and know basic first aid for treating your injuries.

Alderman (1997) suggests this useful checklist of things to ask yourself before you begin walking away from self-harm. It isn't necessary that you be able to answer all of the questions "yes," but the more of these things you can set up for yourself, the easier it will be to stop hurting yourself.

 

While it is not necessary that you meet all of these criteria before stopping SIV, the more of these statements that are true for you before you decide to stop this behavior, the better.
  • I have a solid emotional support system of friends, family, and/or professionals that I can use if I feel like hurting myself.
  • There are at least two people in my life that I can call if I want to hurt myself.
  • I feel at least somewhat comfortable talking about SIV with three different people.
  • I have a list of at least ten things I can do instead of hurting myself.
  • I have a place to go if I need to leave my house so as not to hurt myself.
  • I feel confident that I could get rid of all the things that I might be likely to use to hurt myself.
  • I have told at least two other people that I am going to stop hurting myself.
  • I am willing to feel uncomfortable, scared, and frustrated.
  • I feel confident that I can endure thinking about hurting myself without having to actually do so.
  • I want to stop hurting myself.
[Alderman (1997) p. 132] 

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