Working with Self-injurious Youth in Schools NYASP 2014 Steve Hoff, Licensed Psychologist Associate Professor of School Psychology, The College of Saint Rose, Albany NY THE ALBANY-SCHENECTADY RAILROAD, THE OLDEST IN THE UNITED STATES The Mohawk and Hudson Company – in 1832 the first passenger train in America was run over sixteen miles from Albany (intersection of Madison and Western Aves) to Schenectady According to the US patent office, Seth Wheeler of Albany patented what was called perforated wrapping paper ("toilet" was a sensitive word in 1871). He patented the idea to have the product wrapped around a central tube in 1891, and is also often credited with patenting a bracket to hold those tubes. Google hits for ‘self-harm’ ◦ October 2014 – 3,020,000 Goth Culture Google Images hit for “Emo” Luv-Emo Website – Pics Boys Luv-Emo Website – Pics Girls Barbie Italy Fashion Industry – Considering Skinny Model Ban, 2006 Liposuction – Online Ad for Plastic Surgery Practice The direct, deliberate destruction or alteration of one’s own body tissue without conscious suicidal intent Favazza, Bodies under siege (1987) Self-mutilative behavior is deliberate, nonlife-threatening, self-effected bodily harm or disfigurement of a socially unacceptable nature Walsh & Rosen, Self-mutilation: Theory, research and treatment (1988) Knife Inflicted Wounds Eraser Burns Plastic CD Cover “Carving” Cigarette Burns 4% of general adult population 21% of clinical populations 12% - 38% of college and high school students Whitlock & Knox, Archives of Pediatric Adolescent Medicine (2007) Prevalence by gender ◦ 11 year study of adolescents 12 – 18 487 males, 1633 females (70% female) – but more male cutting likely -at 12 years, M:F ratio was 1:8 -at 18 years, M:F ration was 1:2 Hawton, Journal of Child Psychology and Psychiatry (2003) “Unfortunately, many middle schools and high schools in the US are experiencing an explosion of self-injury among their students” Walsh, Treating self-injury (2006) Why Self-injury? Perfect Case Formulation • How do I understand the presenting problem? • What is the WHY behind the behavior(s)? • What is the Intervention? Normal Adolescent Development Middle school Adolescents What to expect: • Puberty - It comes, but on a variable timetable. Some kids mature early, some late. Boys – body hair, change of voice; Girls – menstruation, breast development • Body image - Cultural/media images and expectations • Authority - Children start to pull away. Less idealized view of parents • Peers - Increasingly important. Bullying and cliques can increase • “Finding their Tribe” - Looking for belonging and meaning. “Where do I fit in”? Social groups, rejection, popularity. • Risk taking – Increases. Smoking, drugs, sexual experimentation • Inconsistent judgment – Thinking and judgment are at times brilliant and at times not • Personality changes – Introspection, egocentrism, self-consciousness, moodiness Emotional distress. The self-injurer is seeking relief – emotion regulation ◦ ◦ ◦ ◦ ◦ Depression Alienation Identity issues Grief/loss Abuse “NSSI functions as a means both of regulating one’s emotional/cognitive experiences and of communicating with or influencing others” Nock, Why do people hurt themselves? New insights into the nature and functions of self-injury (2009) Emotional State Emotion Before During After 76% 30% 14% 6% 45% 72% Confused 63% 29% 28% Clear-headed 11% 34% 47% Depressed 88% 39% 36% 4% 22% 19% Anxious Calm Elated Internet survey of adolescent self-injurers. Murray, Warm and Fox Australian e-Journal for the Advancement of Mental Health (2005) n=128 Brain systems involved in self-injury ◦ ◦ ◦ ◦ Limbic system: regulates mood/affect and pain Dopaminergic systems Serotonergic systems Hypothalmus/pituitary/adrenal axis Studies suggest many systems involved – not a single pathway Many different medications are used to treat: ◦ Antidepressants SSRIs (Prozac, Zoloft) ◦ Antipsychotics (Abilify, Zyprexa, Risperdal, Clozaril) ◦ Mood stabilizers (Depakote, Tegretol, Lithium, Topomax) ◦ Anxiolytics (Ativan, Valium) No medication intervention is well established Must consider long term vulnerability and development, and current context Harper in Walsh, Treating self-injury (2006) School must have a clear protocol for managing self-injury Must be informed by a systems-wide approach Self-injury Suicide Risk Assessment Level of Care Intervention/ Services “Even though most cases of DSH do not end in overt suicide, DSH reflects that potential underlying psychological pathophysiology, and likelihood of eventual death from self-murder, cannot always be predicted or prevented. It is important to take all acts of DSH as serious, and to offer comprehensive management to prevent future acts of DSH and potential suicide”. Greydanus and Apple, The relationship between deliberate self-harm behavior, body dissatisfaction, and suicide in adolescents (2011) Differences in: ◦ ◦ ◦ ◦ ◦ ◦ Depressive symptoms Suicidal ideation Social support Self-esteem Body satisfaction Disordered eating Brausch and Gutierrez, Differences in Nonsuicidal self-injury and suicide attempts in adolescents (2010) Parents must be notified Parents must be educated about self-injury Parents must be part of a clear support plan and must follow through on responsibilities re: outpatient care Family therapy may be indicated if family issues are a key component What is the level of risk? ◦ Question student about the frequency, duration, intensity of self-injury Where does the self-injury occur – school, home, other? Other dangerous behaviors? Drugs, risk taking, etc. ◦ Suicidal intent? ◦ What is the level of peer involvement and need for follow-up? Train staff to recognize and report ◦ What is self-injury? ◦ What should staff be on alert for? ◦ Pay attention in ‘hot spots’ in the school: lunchroom, schoolyard, bathroom, gym ◦ Who should staff tell? School psychologist, guidance counselor, social worker, nurse, administrator, etc. Other self-destructive behavior (substance abuse) Depression/emotional negativity Poor self-esteem Miller & Brock - Identifying, Assessing, and Treating Self-Injury at School (2011) Risky sexual practices Possession of things that could be used for cutting Lieberman et al. (2009) Non-suicidal self-injury in the schools: Prevention and intervention. In Nixon & Heath Self-injury in youth: The essential guide to assessment and intervention. Scratches or burns that don’t appear accidental Frequently bandaged wrists and arms Reluctance to change clothes or participate in gym Wearing long sleeves in hot weather Reasons for self-injury contagion Peer connectedness and identity Competition to be ‘the real cutter’ Expression and communication of feelings Response to manage contagion Individualize and contain – divide and conquer Engage self-injurers, individually, in meaningful ways, e.g. sports, arts, being a helper, USE THE RELATIONSHIP Build system-wide support plan: family, community, etc. for each individual student May have to implement disciplinary response – limit set Individual Groups ◦ Support work in school, intensive work with outpatient clinician ◦ ◦ ◦ ◦ ◦ ◦ Problem solving Self-esteem building Stress management Social skills training/building peer relationships CAREFUL with groups around cutting Activities Sports The Arts: Music, Drama, Visual Arts, Dance Adventure Based Counseling groups Therapeutic animal contact Family work – when appropriate CLINICAL INTERVENTION Think strengths (Brooks – “Islands of Competence”) Get the child to express her feelings Acknowledge that she is hurting and that cutting is her way of coping Treat her with respect, express your belief that she is capable and worthy of selfrespect, able to be responsible and in control Be willing to talk about specifics of cutting & what’s behind it Talk about alternatives to cutting Think illness/pathology Assume that she is cutting to get attention Be shocked, angry, disgusted, disapproving Minimize the importance that cutting holds for her Power Struggle History of conflict in relationships Difficulty having healthy connections Few, if any, positive relationships with adults Relationship with YOU can change her perception of what relationships CAN BE The Relationship Six personality traits necessary to help a teen in crisis: Confidence Empathy Knowledge Understanding Nurturing Optimism Steven Levenkron, Cutting, understanding and overcoming se mutilation (1998) Body Based Therapies “The body keeps the score” (van der Kolk,1996) Rational Emotive Behavior Therapy Albert Ellis Dialectical Behavior Therapy Marsha Linehan Wisdom/Compassion/Mindfulness Self-compassion Wisdom and Compassion in Psychotherapy Germer & Siegel (2012) DIBs – Dispute Irrational Beliefs Double Standard Dispute – “what if this were your friend’s problem?” Catastrophe Scale- “0 is resting at home, 100 is being shot” Reframing – “not devastating, upsetting” or “what are the positives of this situation?” Blow-up Technique – combined with humor – blow out of proportion to show irony, have client laugh at their fear MUST use homework in REBT ◦ Student practices what you came up with together ◦ Practice happens in the real world and the results are brought back in to the work Activity DBT Try to change AND try to Radically accept • Mindfulness • Interpersonal Effectiveness • Emotion Regulation • Distress Tolerance Linehan – Treating BPD (1993) Behavioral Tech • http://behavioraltech.org/index.cfm Breath Interpersonal Effectiveness Emotion Regulation CAT EMOTION CHART Distress Tolerance… The Senses Jen and the Cardinal PROS AND CONS Destructive behavior I wanted to do: __________________ Tolerating distress PROS __________________ __________________ __________________ __________________ NOT tolerating distress PROS __________________ __________________ __________________ __________________ Tolerating distress CONS __________________ __________________ __________________ __________________ NOT tolerating distress CONS __________________ __________________ __________________ __________________ Suicide Risk Multiple contributing factors to consider: ◦ Conduct a thorough psychiatric exam, indentifying risk factors and protective factors and distinguishing risk factors that can be modified from those that cannot ◦ Can use scales. Beck Depression Inventory, etc. ◦ Ask directly about suicide/intent ◦ Determine level of risk: low, moderate, high ◦ Determine treatment setting and plan Multiple attempters at much greater risk M. David Rudd, Ph.D. Treating Suicidal Behavior (2001) Learned skills in problem solving, impulse control, conflict resolution, and nonviolent handling of disputes Family and community support Access to effective and appropriate mental health care and support for help-seeking Restricted access to highly lethal methods of suicide Cultural and religious beliefs that discourage suicide and support self-preservation instincts National Youth Violence Prevention Center (2004) http://www.cssrs.columbia.edu/ Taking Care of the Caregiver: This Means YOU! • Seeing self-injury, and the results, can be shocking, even sickening – it is okay to feel this way • Manage our own stress – Mindfulness, relaxation, alonetime, exercise, etc.