Screening for and Handling Cutting, Burning, and Other Self-Injurious Behaviors

1. Doug Corey, MA, CMHC, Northlands Job Corps Vicki Boyd, PhD, Mental Health Specialist, Humanitas, Inc. Job Corps National Health and Wellness Conference November 2-4, 2011 Baltimore, Maryland Screening for and Handling Cutting, Burning, and Other Self-Injurious Behaviors

2. Learning Objectives • Contrast suicidal behavior and self-harming behavior. • Articulate the function of self-harming behavior. • Describe skills that students can learn to help them cope with difficult thoughts and feelings without engaging in self-harming behaviors. • Suggest different ways these skills might be taught to students while on center.

3. Part 1 Overview

4. Definition by Mayo Clinic Staff • Self injury is the act of deliberately harming your own body, such as cutting or burning yourself. It is considered an unhealthy way to cope with emotional pain, intense anger, and frustration.

5. Self Injury Related to Mental Illness • Researchers have not been able to trace cutting to any single disorder • Some clinicians have insisted that cutting is frequently found with individuals suffering from borderline personality disorder • There is no evidence highlighting borderline personality disorder

6. Upgrading the DSM • Those in charge want to elevate cutting from a symptom to a disorder • The disorder would be called “non-suicidal self injury” • The jury is still out

8. The History of Self-Mutilation • Throughout history, the act of bleeding, bloodletting, and cutting share the same result: RELIEF • Relief from illness, relief from pain, relief from guilt and shame, always relief • The definition of self injury/cutting remains the same today

9. The History of Self-Mutilation • “There is no remedy as miraculous as Bleeding” -1645 • Egyptians may have practiced bleeding as early as 2500 BC • Hippocrates (Father of Western medicine) wrote in the 4th and 5th centuries that bleeding addressed nearly everything that ails you

10. The History of Self-Mutilation • Early Roman church records indicate both bleeding and self injury were good for the body and the soul (The DaVinci Code) • Middle Ages: The Pope forbade all clergy from bloodletting, hence barbers and surgeons were the only ones allowed to perform the procedure

11. The History of Self-Mutilation • The second medical text ever printed on Gutenberg’s printing press was a “Bloodletting Calendar” in 1462 • The Arab world embraced bloodletting as well, but bled from the opposite side as the malady. (The Greeks bled from the same side as the ailment) • George Washington was likely bled to death

12. My Clinical History with Cutting • Early years of out-patient experience: • Patients were typically college students and college dropouts • Psychodynamic and behavioral approaches were the order of the day

13. My Clinical History with Cutting • Early years of in-patient experience: • University of Washington in-patient psychiatric unit: Female, age 22 • Veterans Administration Neuropsychiatric Hospital: Male, age 37

14. Part 2 Self Injury vs. Suicide

15. Self Injury vs. Suicide • Cutting is rarely related to suicide • Cutting is believed to bring an immediate, albeit momentary sense of calm and release of tension • A strangely effective coping behavior (though a self-destructive one)

16. Rate of Successful Suicide • Firearms 59.3 (2/3) • Suffocation 24.8 (1/4) • Poisioning 6.4 • Fall 2.9 • Other 2.5 • Drowning 0.8 • Fire / Burning 0.5 • Transportation 0.5 • Cutting 0.4 %

17. Intent & Methods Suicide Self-Injury Relief from pain Too much ortoo little emotion Frequent Several methods • Escape pain • Unconsciousness • Rarely chronic • Few methods

18. Pre & Post Experience Suicide Self-Injury Intermittent Uncomfortable Some optimism Choices & control Rapid relief • Persistent • Unendurable pain • Hopeless/helpless • Only way out • Feel worse

19. Core Problem Suicide Self-Injury Overwhelmingemotions Body alienation Poor body image NEW GROUP Intense stress Poor self-soothing Peer endorsement • Depression • Rage aboutunendurable pain

20. Part 3 Screening and Responding

21. New Group • May not have history of abuse • Often have major strengths • Large group of friends • Peers play an important role: • Also engaging in self-injury • Reinforcing with support

22. Initial Response • Use the client’s language • e.g., “cutting, scratching, carving” • It’s joining, respectful, empowering • Rule out suicidal intent • Avoid inflammatory terms • Not “suicidal” • Not “self-mutilating”

23. Terms to Avoid • Not a “Suicidal Gesture” • Inaccurate and misleading • Can lead to empathic failure-“You don’t get it!” • Not “Self-Mutilation” • Too extreme and sensational • Self-injury  mild to moderate damage

24. It’s Not Just for Attention • A pejorative response, stigmatizing • Often in response to distress • Many other ways to get attention • But can be a secondary reinforcer • Those who inadvertently reinforce the behaviorneed to be part of the response plan

25. Problematic Responses • Recoil, Shock, Avoidance • Too upsetting • Disorganizing for the caregiver • Stigmatizing for the student • Concern & Support • Inadvertently becomes reinforcing • The more intense the response, the greater the risk of reinforcement

26. Concern vs. Compassion • Concern & Support (problematic) • Suggests affective intensity • A yearning to be of assistance • A desire to quickly protect & intervene • Compassion (recommended) • Acceptance • A neutral stance • No expectations of immediate change

27. Nonjudgmental Compassion • They’re used to harsh, pejorative judgments • Nonjudgmental compassion is welcomed • Indicates you are ready to hear the rest of their story • Encourages full disclosure

28. Self-Injury Log • Baseline of wounds & episodes • Extent of physical damage • Body area • Use of a tool • Room or place of self-injury • Social context

29. Self-Injury Log • Antecedents • Cognitive (automatic thoughts & core beliefs) • Affective (primary reason for self-injury) • Behavioral (triggers and precipitants) • Consequences or Aftermath • Specifics of psychological relief • Self-care and communication • Social reinforcement

30. Self-Protection Contract • Commitment to reduce frequency • Replacement skills • Self-soothing & distracting • Reward (often self-reward) • No punishment if not achieved • Or they will withhold information • Unable to stop without treatment • Contract for tx (or empathic failure)

31. Consequences at Job Corps • Open for Discussion: • Do we put everyone who engages in self-injury on a medical leave? • Would this drive the behavior underground? • They can’t change without treatment • Must rule out risk to self and others • They may need treatment elsewhere

32. Using Replacement Skills • Select the right skills • Practice diligently • Start when student is calm & focused • Over learning skills will help later • Replacement skills have worked for many others and they will work for you if you find the right skills and practice, practice, practice

33. Replacement Skills • Negative replacement behaviors • Mindful breathing skills • Visualization techniques • Physical exercise • Writing • Artistic expression • Playing or listening to music • Communication with others

34. Diversion Techniques • Need multiple techniques • Watch TV • Play video games • Read a book • Not a higher-order skill • To use as they are learning new skills • They already do these things… • So they may not be so effective

35. Common Approaches • Cognitive Behavioral Therapy • Dialectical Behavioral Therapy • Body Image Work • Exposure Treatment • Trauma Resolution

36. Dialectical Behavioral Therapy • DBT- Developed by Marsha Linehan • Treating Borderline Personality Dx • Teaching skills to regulate emotions • Mindfulness • Distress Tolerance • Emotional Regulation • Interpersonal Effectiveness

37. Bringing DBT to Job Corps • Very helpful with difficult consumers at a community mental health center • Recently applied more broadly • Most self-injury is an effort to cope with strong emotions • At Job Corps, students… • Complain about “drama” • Are drawn to it • And are triggered by the drama

38. Group of Young Women • Had a history of self-harm • Living in the same dorm/room • Triggering and reinforcing each other • Decided to meet with them as a group

39. First Group • Ground Rules (respect, confidentiality…) • Establish Safety and Support • Don’t want to make them feel bad • Not judging them in any way • They are doing the best they can • Intro to DBT • Biosocial Model • Validating & Invalidating Environments

40. Validating Environment • Imagine you’re a caregiver of a young child (2 or 3 years old) • Scared by a dog... • that you know is not a threat • Child runs to you… • What would you do?

41. Validating Response • What You Do: • Comfort them physically • Reflect their feelings • Reassure them verbally • What This Does: • Teaches them to identify feelings • Feelings are uncomfortable, but it’s OK to express them • Feelings will pass and you can go on

42. Invalidating Response • How their caregivers responded: • Many examples of invalidation • They had all been traumatized • What this taught them: • Hide your feelings • Bad things will happen if you express your emotions • They keep building up until relief through self-harming behaviors

43. What About Their Group? • Immediately understood they had been inadvertently triggering and reinforcing self-harming behavior • What else could they do? • It’s how they were raised • It’s all they know

44. Self Harm as Coping • DBT Maxim • Solve the problem if you can • If you can’t solve it, survive it • Self-harm • An effort to survive a problem they couldn’t solve • They were doing the best they could in their invalidating environment

45. Other Coping Skills • Skills Training Manual for Treating Borderline Personality Disorder, Marsha Linehan (1993), New York: Guilford Press

46. Distraction Skills • Activities • Contributing to others • Compare your fate to others • Opposite emotions • Pushing away • Distracting thoughts • Other sensations

47. Walk On… • Ground Hog Story • Anger isn’t bad, but… • If you keep concentrating on it, • things won’t get better and • they might get worse

48. Homework • Try some distraction skills • Try validating each other

49. Second Group • Emotional mind • Valuable and necessary • Can’t always act from emotion • Reasonable mind • Logical, problem solving • Sometimes eclipsed by emotion • Wise mind

50. Distress Tolerance • Imagery • Meaning or Purpose • Prayer • Relaxation • Focus one thing; in the moment • Brief vacation from your troubles • Encouragement