Understanding and Addressing Self-Injury in SchoolsSara BurdBehavioral Health CoordinatorReading Public Schoolssara.burd@reading.k12.ma.us

Self- Care for Today

Our topic is sensitive and at times participants may feel uncomfortable or experience difficulty processing information.

Please take care of yourself and feel free to step out of the room, take a break, grab a drink, etc. as needed to care for your needs.

Different Terms• Self-harm• Self-injury• Self-mutilation• Repetitive Self-Mutilation Syndrome (RMS)• Para Suicidal behavior• Cutting• Self-abuse• Self-inflicted violence (SIV)• Self-injurious behavior

DefinitionSelf-injury is a volitional act to harm one’s body without intention to die as a result of the behavior.

(Favazza, 1996, 1987; Simeon & Favazza, 2001)

The deliberate, impulsive mutilation of the body, or body part, not with the intent to commit suicide, but as a way of managing emotions that seem too painful for words to express.

While self-injury is generally not about suicide, the behavior comes at the cost of:

• Bodily harm• Potential scarring• Social stigma

Methods of Suicidal Behaviors• High lethality behaviors that frequently pose risk to life and

may result in death include:• Use of gun• Suffocation ( hanging)• Poisoning (overdose, carbon monoxide)• Jumping from a height

Caution!• While suicide and self-injury are separate and distinct

behaviors, they can occur in the same individual.

• Ongoing assessment should focus not only on self-injury but also on suicidal thoughts, plans and behaviors.

Methods• Cutting• Scratching• Burning• Preventing the skin

from healing• Bruising or breaking

bones• Head banging• Biting• Hair pulling• Punching self or objects• Hitting the body with

objects• Constricting the flow of

air passages• Limiting the blood

supply to body parts• Cutting off body parts

Self-Harm Behaviors

Direct• Suicide attempts• Major self-mutilation• Stereotypic self-injury• Moderate/superficial

self-injury

Indirect• Substance abuse

• Eating Disorders• Physical risk-taking• Situational risk-taking• Sexual risk-taking• Unauthorized• discontinuance or• misuse of psychotropic• medications

Incidence and Prevalence• Varying statistics• 1% of population• (National Mental Health Website)• 4% in a community sample of adolescents• (Garrison, et al. 1993)• 13.9% of adolescents in more recent school• samples• (Ross & Heath, 2002)

Incidence and Prevalence• Age of onset is usually age 12-14• More females than males, however, significantly present in

both genders.• All races and socio-economic groups

Myth Busting• Cutters are suicidal• Self-decoration is self-injury• All have been physically or sexually abused• Self-injuring adolescents have borderline personality disorder• These kids need to be hospitalized

(see myth vs fact handout)

Possible Motivators

Self-injury is seen as a maladaptive coping mechanism

• To reduce intense feelings such as anxiety, depression, anger, sadness, tension, contempt, guilt and shame

• To relieve too little emotion or states of dissociation/numbness

Why People Self-InjureTo communicate something:

• For acknowledgement (please acknowledge I am upset)• To punish (look what you’ve done to me)• To change behavior of others• To produce withdrawal (now you’ll give me space)• To coerce ( if you break up with me, I’ll hurt myself)

To elicit a response from caregivers, family members or significant others:

• Competition for scarce resources (squeaky wheel)• Anticipation of aversive consequences (If I hit you I get

suspended, if I cut myself I don’t)

Students Report They Harm to:• relieve tension• feel alive inside• gain control• numb themselves• vent anger• re-associate• relieve emotional• distress or overwhelming

feelings• gain euphoria• stop bad thoughts• purge out bad feelings

• hurt and/or control others• feel the warm blood• see “red”• to release emotional pain• because their friends all do it• scars show battles won• self punishment• for ritualistic nature• to replace emotional pain with

physical pain• immediate release for anger

Experiences that May Trigger Self-Injury

• Recent loss• Peer or family conflict• Intimacy problems• Body alienation or dissociation related to abuse• Impulse control problems• Drug or alcohol use• Trauma

Risk Factors• Having friends who self-injure and communicate about the behavior

extensively• Being prone to intense emotional distress with limited abilities to

manage it• Episodic anxiety, depression• Spending time on websites, message boards or chat rooms

dedicated to self-injury• Being pre-occupied with music, stories, art, about self-injury• Performance problems or stresses in areas of school, work, athletics

or extracurricular activities

Physical Signs• Inappropriate clothing for the weather• Blood stains on clothing• Unexplained scars, bruises, or cuts• Possession of sharp implements (razor blades, thumb tacks,

knives, etc.)• Secretive behavior - spending unusual amounts of time in

bathroom, other isolated areas

Emotional Signs• Unable to cope with strong emotions• Excessive anxiety and fears• Excessive rage, depression• Poor self-esteem or self-loathing• Not connected with positive support system• Increased isolation and withdrawal• Art and writing displaying themes of pain, sadness, physical

harm• Changes in social interactions or interests

Can Be Ritualistic in Nature

• Certain times• Certain rooms• Certain objects

Co-morbid Disorders• Anxiety• Depression• Bi-Polar• PTSD• Eating Disorders• Substance Abuse• Borderline Personality

Protective Factors• Healthy emotion regulation skills• Ability to self-soothe• A strong support network• A positive body image • Positive thoughts and beliefs

Cognitive Behavioral Therapy

Examples of distortions in thinking:1. Self-injury is acceptable2. One’s body and self is disgusting, and deserving of self-punishment3. Overt action is needed to tolerate unpleasant feelings and communicate feelings to others4. Self-injury doesn’t hurt anyone5. It’s the only way to know people care6. It keeps people away7. If I don’t have it, I will kill myself. It’s the only thing that works.8. I can’t control it.

Other Types of Therapy• Family therapy• Addiction treatment• Trauma/abuse treatment• Medication• Dialectical Behavioral Therapy• Combination of above• Group therapy not recommended usually

Therapist Recommendations• Many therapists not well-trained in areas of self- inflicted

violence• Much secrecy surrounding the behavior• Goals of therapy should be related to underlying cause of pain

Examples of Positive Coping Strategies

• Communication strategies• Exercise programs• Relaxation, stress management• Mindful Breathing (Kabat-Zinn, 1990)• Meditation, Visualization• Art therapy• Journaling• TALK TO SOMEONE!!!• Students should be in school during treatment - respond well

to structure, normalcy, safety

S.A.F.E (Self-Abuse Finally Ends)1-800-DON’T CUT• Inpatient and out patient services for serious self-injury• When self-injury is interfering with ability to function• Person must self refer• Insurance is accepted

Mobile Crisis Unit• Eliot Community Human Services

• 24/7 Prompt team response to behavioral health crisis

• 1-800-988-1111• www.eliotchs.org• Donna Kausek, Program Director

School Best Practices

What School Mental Health Can Do• Provide awareness and knowledge• Educate students to report self and others• Educate school staff• Use a team approach, when necessary• Assess for safety, co-morbid disorders and suicide• Develop safety plan• Notify and collaborate with parents• Collaborate with community support• Control the contagion effect

Awareness and Knowledge

It is our professional & ethical obligation to:• Practice within the boundaries of our competence• Be able to identify students who self-injure• Differentiate self-injury from suicide attempts• Know that it is not “just attention getting” behavior• Understand the contagion effect• Know our community resources to make appropriate referrals• Understand our legal & ethical obligation to report

Educate Students to Report • Report all dangerous behaviors to an adult who can help.• Do not use awareness campaigns about this topic or describe

behaviors to students.

SOS: Signs of Suicide ACT- Acknowledge Care Tell

Educate School Staff• Educate them about the warning signs• Understand self-injury as coping attempt not suicide attempt• Train staff to identify and appropriately respond to these

students• Staff should not just tell the student to “stop”• Report behavior to school mental health personnel

Responding to the Student

Do• Approach the student in a calm and caring way• Accept him/her even though you do not accept the behavior• Let the student know that you care about them and believe in

their potential• Understand that self-injury may be their way of coping with

emotional distress• Understand that self-injury is usually not about suicide• Refer the student to the counselor, social worker, nurse• Offer to go with the student to see the professional helper• Remember that the teachers role is not to solve the problem

but to refer the student to a trained professional

Responding to the Student

Don’t• Say or do anything to cause the student to feel guilt or shame• Act shocked or appalled by their behavior• Talk about their self-injury in front of the class or around peers• Lecture them as to what you think they should do• Judge them or conclude they are doing it just for attention• Promise the student to keep the self-injury confidential under

any circumstances• Use punishment or negative consequences if a student self-

injures• Make deals in an effort to get the student to stop self-injuring

Assess for Co-morbidity and Suicide

• Check for signs of other co-morbid disorders such as depression or drug use.

• Assess for suicidal ideation• Be direct with questioning about topics involving danger to

self or others

Develop a Safety Plan• Short term plan serves to help stabilize student until

community support can begin• Do not emphasize expectation that student is not to self-

injure; to stop behavior• Help students to identify the triggers for the behavior and

possible physical cues• Help to understand the function of the behavior• Encourage student to talk to someone before cutting - give

help line phone numbers• Remove objects, etc. when possible

No Harm Contracts

• What is a no-harm contract?

• Not recommended as a strategy for working with these students in schools without other intervention

Reporting Self-Injurious BehaviorThree situations in which the school mental health provider is obligated to share confidential student/client information:

1. When student requests it.2. Situation involving danger to the student or others (duty to protect).3. When there is a legal obligation to testify in a court of law.

Ethical ConsiderationsNASW, NASP and APA• Do no harm• Provide services within competency and enlist assistance of

others• Inform of limits to confidentiality• Promote parental participation in designing services provided

to children• Referral for service

Other Considerations for Limits to Confidentiality• Important differences from therapist-client relationship• Permission needed for psychological treatment in schools• School district policy

Parent Notification• Notify and involve parents• Ascertain whether parents already know of behavior• What is already in place to support student?• Gather additional history• Document your parent contact

Collaborate with Community Support

• Get a release to communicate with student’s therapist• Understand the treatment goals and techniques in order to

reinforce in the school environment• Our observations and feedback can often be helpful to

therapists

Controlling the Contagion EffectAssess factors that may be contributing:• Direct modeling influence• Disinhibition• Competition• Peer hierarchies• Desire for group cohesiveness• Pseudo-contagion episodes

(Walsh, 2005)

Controlling the Contagion EffectStrategies for managing and preventing contagion:• Identify the primary status peer models• Communicate with them that they are hurting their peers by

communicating about self-injury• Encourage them to communicate with school supports, family,

or therapist• Ask them not to appear in school with visible wounds or scars• In rare cases, students may have to be dealt with in a

discipline manner(Walsh, 2005)

Personal Reactions to Self-Injury• Violent nature of self-injury can be unnerving.• Watch for anger, disgust or sadness responses.• Growth and change can be slow.• Requires a large emotional investment. Watch for

helplessness, guilt or betrayal responses.• Over-empathy or over-reaction.• Watch for “attention-seeking”response

Practice

Find a partner…

You are a teacher of Karen’s. On Monday morning Karen pulls you aside with tears in her eyes and tells you she had a very bad night. Karen lifts her sleeves up and reveals bandages covering cuts that were made recently. Karen tells you that she is going to need some time to recover and asks that you be lenient and not call on her in class today. Karen turns to walk away.

• You are a teacher of Ron’s. Ron is a leader in his classes and a great student. On Wednesday you notice that Ron hasn’t taken off his coat for hours despite the fact that the heat is pumping hard and everyone is sweltering. His coat is wide open and it appears he has short sleeve on underneath. You begin to observe more closely and notice that Ron is constantly pulling his sleeves down to cover his hands.

• You are Jamie’s counselor. Jamie has just shared with you that she self-injures by burning large portions of her skin with her hair straightener. Jamie does not feel she is able to stop or slow her behavior right now and is particularly stressed and triggered by her recent breakup. Jamie does not want you to tell anyone.

• You are Karen’s counselor. Remember Karen? Karen was referred to you by her classroom teacher and has shared with you the details of her self-injurious behavior. You are about to call her parents. Karen is worried her parents will overreact or punish her.

Mindfulness• Outside- In• Leaves on a river• Raisin reflection• The Guest House Poem

Yoga 4 Classrooms

• Balloon Breath• Ocean Breath• Bumblebee Breath• Power Breath• Rock the Baby• Monkey Arms• Chair Pose• Eagle Pose• King Dancer• Tree• Half Sun Salute• Warrior

• Loosen the knots• Magic Massage• Washing Machine• Positive Opposites• Change the Channel

ResourcesSELF-INJURY:Awareness and Strategies for School Mental Health ProvidersLinda Kanan, PhD, Jennifer Finger, MSW, LCSW

New Developments in Understadning and Treating Self-InjuryBarent Walsh, Executive Director: The Bridge of Central Massachusetts, Inc

SOS: Signs of Suicide Middle and High School Suicide Prevention Program

Yoga 4 Classrooms: Tools for Learning, Lessons for Life. Lisa Flynn