A COLLABORATIVE APPROACH TO

UNDERSTANDING & TREATING SELF-

HARMING BEHAVIOURS

Theresa Faubert, BA, CYW, CYC (Cert)

theresa.faubert@rogers.comPatty Hayes, MSW, RSW, MDiv

pattyhayespcc@gmail.com

GOALS FOR THE WORKSHOP Begin to define and understand what

constitutes “self-harming behaviours.”

Examine these behaviours from a bio-psycho-social perspective.

Look at some possible intervention strategies, including a harm reduction approach.

WHAT IS SELF-HARM? The term self harm is also referred to as:

deliberate self harm (DSH), intentional self harm, self mutilating behaviour (SMB), self wounding, self inflicted violence (SIV), non-suicidal self injury (NSSI) and parasuicide as well as (failed) suicide attempts.

The motivation of the act is what differentiates the diagnosis and treatment.

WHAT IS SELF-HARM (CONT.) Self harm is distinguished by three

identified meanings “Coping, Control and Validation.”

Coping: is described as “tension release, alleviating unpleasant emotions and inducing a shift in affective state” Control over a chaotic environment; and Validation of self by concretizing emotional or psychological pain.

SELF-HARM V. SUICIDE: A CONTINUUM Motivation distinguishes self-harm from

suicidal behaviour. There seems to be common consensus

that methods involving low lethality are more apt to constitute self-harm.

Self-harming behaviours are on a continuum.

Thrill NSSI Suicidal Suicidal

Seeking Ideation

PREVALENCE As a result of the shroud of secrecy

inherent in acts of self harm, incidences are typically under-reported.

4% of general population; 21% of “clinical populations without mental retardation or developmental disability.” (Kress, 2003).

Average age of onset is 12-15 years old. Self-harming behaviours in younger

children may go unnoticed (picking at scabs, falling down to get hurt).

PREVALENCE CONT. Research indicates that seniors are

more likely to use poisoning, more more likely to be hospitalized in response to their self-harming behaviours, and have episodes of self-harming which are less likely to result in completed suicide.

Numerous studies have shown that self-harming behaviours can be found across cultures, ethnicities and language groups.

TAKING A BIO-PSYCHO-SOCIAL APPROACH TO UNDERSTANDING SELF-HARM

No one dimension can account for why someone might engage in self-harm behaviours.

Each person engages in self-harm for a different set of reasons.

Our best framework for understanding self-harming behaviours uses an ecological approach.

AN ECOLOGICAL APPROACH

Using an ecological approach to understanding self-harm allows us to identify key areas and examine how the interrelation between the key domains affect a youth to engage in self-harming behavior.

BIOLOGY - THE BRAIN & BODY AT WORK Psychiatric/Medical Issues

DepressionBipolarSchizophreniaAnxietyEating DisordersDementia (in older adults)

Endorphins – a biochemical high

BIOLOGY – THAT’S USING YOUR BRAIN! Teen Brain Development – frontal lobe is

not fully developed which effects, among other things, impulse control and executive brain functioning.

Research is also showing that prolonged exposure to trauma and neglect can have an effect on brain functioning and development.

SOCIAL - GENDER DIFFERENCES Female to male ratios range from 2:1 to 20:1

depending on the study. Recently, however, research has indicated that

the number males engaging in self harm are on the rise.

Boys’ and men’s self-harm behaviours tend to be labeled as “risk taking.”

Males tend to complete more suicides than females.

Male and Female social constructs may have an impact on the view of self-harm behaviours as research has historically been conducted with females. Clinically we are seeing more males presenting with cutting behaviour.

SOCIAL/ENVIRONMENTAL - CONTAGION FACTOR Studies are conflicting about whether

or not self-harming behaviours are subject to the contagion effect.

There are some social groups in which engaging in self-harm is an identifying factor (emo v. scene kids).

VALIDATING ENVIRONMENT One potential risk factor is to what

degree a person’s environment is validating or leads a person to doubt her/his experiences.

Factors which may create a invalidating environment include:AbusePoor “fit” between the individual and others

who are close (eg. Poor parent-child fit)

PSYCHOLOGICAL – WHAT FUNCTION DOES THE BEHAVIOUR(S) SERVE?

Cope with tension and anxiety. Express repressed emotions, especially

anger. Re-create the trauma. To have a sense of control Return from Dissociative States. Self-Hatred/Punishment.

FUNCTIONS (CONT.) Self-medication

Break through numbness.Get a rush/high from endorphins.

To “gain attention”/call attention to something deeper.

ASSESSMENT Observe for clues if the person hasn’t

disclosed yet (eg. Long sleeves on a hot day).

For those who have disclosed:Ask where they cut (you’ll have to gauge

whether/when to inspect).Ask what they use.Ask how often and when the last time was.

ASSESSMENT CONT. Ask questions to get a first sense of the

underlying psychological process:Do you remember cutting yourself?What do you usually feel just before you

cut? (numb, angry, lonely, anxious, etc.)What do you feel afterwards? (relief, shame,

a “high”, numb)Do you plan ahead or is it spontaneous?

INTERVENTIONS What interventions are used depend on

whether or not the person is ready to stop the behaviours.

BUILDING A MULTIDISCIPLINARY TEAM Medical – to provide a safe &

compassionate space to address medical issues which may arise, including those not related to NSSI.

Psychiatry – to assess for and manage potential underlying psychiatric issues.

Social Work/Counselling – to provide individual & family support; to help case manage.

Other Collaterals – eg. School; spiritual religious supports; social supports, etc.

HARM REDUCTION If the person is not prepared to stop, use

harm reduction strategies:Provides for some health and safety

measures.Allows the person to start to feel some

sense of control over her/his body and actions.

Using Motivational Interviewing at this stage may be helpful in building a person’s motivation and confidence to change.

HARM REDUCTION STRATEGIES

Assisting the person to get appropriate medical supplies.

Teaching proper wound care. Teaching proper sterilizing & disposal

techniques for the “implements” used for self-harming.

Safety planning around medical and mental health emergencies.

Coaching the family to let the person tend to her/his own wounds.

MOTIVATIONAL INTERVIEWING Use various empathy and advanced

empathy responses to:Demonstrate you are non-judgemental.To help both you and the person begin to

explore some of the factors which may be driving the behaviours.

To “roll” with resistance.To help develop discrepancy between the

person’s preferred life goals and her/his current behaviours.

MOTIVATIONAL INTERVIEWING Use Decisional Balance Sheets to:

Gain a better understanding of what factors may be keeping the person “stuck.”

To increase motivation.To increase confidence.To begin to develop strategies/plans specific

to the person.

STOP THE RIDE, I WANNA GET OFF! (WHEN THE PERSON IS READY TO STOP)

Manage any on-going psychiatric issues. Support the person in seeking out

appropriate kinds of therapy. Cognitive Behavioural Therapy (CBT) Dialectical Behavioural Therapy (DBT)

Recovery is a process, not a product. Expect there will be slips and that progress will not always be even.

CBT - THOUGHTS, FEELINGS & BEHAVIOURS Thought Records

What happened?What were the feelings and at what

intensity?What were the thoughts?What were the behaviours?

Behavioural interventionsActivity schedulingSubstituting other behaviours

Relaxation trainingDeep breathingProgressive muscle relaxationVisualization

DBT Usually involves group and individual

work. Elements include:

Emotional RegulationProblem Solving Skill DevelopmentDistress Tolerance SkillsMindfulness

THERE IS HOPE FOR RECOVERY!! “I had always sensed that [Self Inflicted

Violence], for me, was related to survival. I did not understand all the dynamics bringing on SIV, but I had experienced it as an alternative to suicide or psychic implosion… Without survival, there would have been no possibility for healing.” - Ruta Mazelis (emphasis ours)