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

Doug Corey, MA, CMHC, Northlands Job CorpsVicki Boyd, PhD, Mental Health Specialist, Humanitas, Inc.

Job Corps National Health and Wellness ConferenceNovember 2-4, 2011Baltimore, Maryland 1

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.

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Part 1

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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.

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

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

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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

“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

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

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

Early years of out-patient experience: Patients were typically college students

and college dropouts Psychodynamic and behavioral

approaches were the order of the day

Early years of in-patient experience: University of Washington in-patient

psychiatric unit: Female, age 22 Veterans Administration

Neuropsychiatric Hospital: Male, age 37

Part 2

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Cutting is rarely related to suicideCutting 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)

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 %

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SUICIDE

Escape pain Unconsciousness Rarely chronic Few methods

SELF-INJURY

Relief from pain Too much or

too little emotion Frequent Several methods

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SUICIDE

Persistent Unendurable pain Hopeless/helpless Only way out

Feel worse

SELF-INJURY

Intermittent Uncomfortable Some optimism Choices & control

Rapid relief

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SUICIDE

Depression Rage about

unendurable pain

SELF-INJURY

Overwhelmingemotions

Body alienation Poor body image

NEW GROUP Intense stress Poor self-soothing Peer endorsement

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Part 3

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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

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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”

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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

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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

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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

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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

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They’re used to harsh, pejorative judgments

Nonjudgmental compassion is welcomed

Indicates you are ready to hear the rest of their story

Encourages full disclosure27

Baseline of wounds & episodes Extent of physical damage Body area Use of a tool Room or place

of self-injury Social context

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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

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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)

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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

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Select the right skillsPractice 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

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Negative replacement behaviorsMindful breathing skillsVisualization techniquesPhysical exerciseWritingArtistic expressionPlaying or listening to musicCommunication with others

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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

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Cognitive Behavioral TherapyDialectical Behavioral TherapyBody Image WorkExposure TreatmentTrauma Resolution

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DBT- Developed by Marsha LinehanTreating Borderline Personality DxTeaching skills to regulate emotions

Mindfulness Distress Tolerance Emotional Regulation Interpersonal Effectiveness

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Very helpful with difficult consumers at a community mental health center

Recently applied more broadlyMost self-injury is an effort to cope

with strong emotionsAt Job Corps, students…

Complain about “drama” Are drawn to it And are triggered by the drama

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Had a history of self-harmLiving in the same dorm/roomTriggering and reinforcing each otherDecided to meet with them as a

group

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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

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Imagine you’re a caregiver of a young child (2 or 3 years old)

Scared by a dog... that you know

is not a threatChild runs to you…What would you do?

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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

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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

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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

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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

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Skills Training Manual for Treating Borderline Personality Disorder, Marsha Linehan (1993), New York: Guilford Press

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ActivitiesContributing to othersCompare your fate to othersOpposite emotionsPushing awayDistracting thoughtsOther sensations

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Ground Hog Story

Anger isn’t bad, but… If you keep concentrating on it,

things won’t get better and they might get worse

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Try some distraction skills

Try validating each other

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Emotional mind Valuable and necessary Can’t always act from emotion

Reasonable mind Logical, problem solving Sometimes eclipsed by emotion

Wise mind49

ImageryMeaning or PurposePrayerRelaxationFocus one thing; in the momentBrief vacation from your troublesEncouragement

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There’s a right way to feel in every situation Letting others know how I am feeling bad is weakness Negative feelings are bad and destructive Being emotional means being out of control Emotions can just happen for no reason Some emotions are really stupid All painful emotions are a result of a bad attitude If others don’t approve of my feelings, I obviously

shouldn’t feel the way I do Other people are the best judge of how I am feeling Painful emotions aren’t important and should be

ignored

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Get training in DBT

Skills Training Manual for Treatment Borderline Personality Disorder by Marsha Linehan

Adapt the material for Job Corps groups

Develop staff trainings: Responding to students Dealing with their own emotions

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Worked with self-injuring persons since the late 1970’s

Executive Director:The Bridge Central Massachusetts Network of 30 mental health programs

Conducted research, written extensively, and presented internationally on self-injury

He has also consulted on the topic in many settings (schools, clinics, and hospitals)

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Job Corps Health and Wellness Website

National Public Radio (NPR.org) ‘Cutting Elevated from Symptom to

Mental Disorder’ by K. Masterson, February 10, 2010

‘The History and Mentality of Self-Mutilation’ by Alix Spiegel, June 10, 2005

S.A.F.E. Alternatives: A program for Self-Mutilatorswww.mayoclinic.com/health/self-injury/DS00775

Factsheet: Self-Injury. Mental Health America.www.nmha.org/go/information/get-info/self-injury

Starr, Douglas. BLOOD: An Epic History of Medicine and Commerce. New York, NY: Perennial, 2002