The scope of self-injury in adolescence

The scope of self-injury in adolescenceStephen P. Lewis, PhDAssistant Professor, University of Guelph

Questions we’ll answer today

What is self-injuryWho self-injuresWhy do youth self-injureWhat are the risksWhat is the role of social mediaWhat can we do

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What is self-injury?

Defining self-injury

Refers to the intentional destruction of one’s body tissue in the absence of conscious suicidal intent and for purposes that are not socially or culturally sanctioned or accepted

(Nock & Favazza, 2009)

Non-suicidal Self-injury (NSSI)

NSSISuicide

Self-injury vs. suicide

Nonlethal Intent Lethal Intent

Lower Severity Higher Severity

Higher Frequency Lower Frequency

Key differences…

Muehlenkamp, 2005; Nock & Favazza, 2009

What isn’t self-injury?

Tattooing, Body piercing

Binging/purging, self-starving

Overdosing/self-poisoning

Accidental cuts or bruises

Smoking

Drug/alcohol abuse

Nock & Favazza, 2009

How people self-injure: Methods

Most commonly cited:

Cutting, carving, scratching, scarping

BurningHitting/Bruising Skin-picking

Wound Interference Self-embeddingBiting

Nock & Favazza, 2009; Whitlock et al. 2006

Cutting itself RARELY results in suicide

Who self-injures?

14-24% of youth and young adults have self-injured

Many of these repeatedly self-injure

Lewis & Santor, 2008; Klonsky & Lewis, 2010; Rodham & Hawton, 2009; Whitlock et al., 2006

Prevalence: Adolescence

Canada/ US

12-15%

A recent Canadian study1 in 7

Many of these will repeatedly self-injure

Lloyd-Richardson et al., 2008; Muehlenkamp & Gutierrez, 2004; Nixon et al., 2008; Ross & Heath, 2002

Some studies report higher rates (up to 48%)

Sex differencesMixed evidence; girls may self-injure more

frequentlyConsensus: Boys & girls self-injure; boys seek help

less

Females: scratch, pinch & cutMales: punch objects/hit

Females: wrists, thighsMales: hands

Methods

Body Location

Whitlock et al., 2006

Why do youth self-injure?

How will you know I am hurting,

If you cannot see my pain?

I wear it on my body

To say what words cannot explain

-Teenager on an online forum

Why do youth self-injure?

It’s NOT about attention-seeking…but, rather…

Emotion Regulation To cope with difficult feelings

Self-punishment

Anti-Dissociation

Expressing self-hate/punish self

To feel real or less numb

Why do youth self-injure?

InterpersonalCommunication Tell others how one feels

To set boundaries

Anti-suicide

Expressing self as distinct

To avoid suicide urges

Functions may co-exist (& this is a non-exhaustive list)

What are the risks?

See Nock, 2009; Skegg, 2005; Walsh, 2006

Mental Illness (e.g., depression, eating disorders)

There is no single ‘path’ to self-injury

Difficulty coping with negative feelings

Substance Abuse

Interpersonal difficulties, maltreatment

Risks FOR self-injury

Risks OF self-injury

See Nock, 2009

Difficulty talking to others/feeling connected

Repeated self-injury, scarring & more severe self-injury

Worsening of symptoms (e.g., depression, anxiety, stress)

Sometimes it can lead to suicidality

Self-injury may lead to the following…

NSSI & Suicidality: A closer look

What is the role of social media?

Self-injury online…

Searching for ‘self-injury’ or ‘self-harm’ In Google yields millions of hits

This is not a bad thing….

Though, it may be (sometimes)…

Self-injury online: Personally-made sites

Lewis & Baker in press

Descriptions of self-injury

Pictures of self-injury

Addictive, hard to stop, helpful (to cope) & not always painful (at the time)

Graphic descriptions of different episodes

Graphic, and typically of cutting

Many sites are shared via self-injury e-communities

Self-injury online: Personally-made sites

Lewis & Baker in press

NSSI Messages

Triggering Material

Mixed/ambivalent messages

Few pro-self-injury messages

Direct reports that material is triggering(imagery & text-based content)

This has been based on clinical assumption

Self-injury online: Discussion Boards

Whitlock et al. 2006

Motives for discussing self-

injury

What is discussed?

Acceptance, support, validation, connection/communication

Self-injury experiences, questions shared, etc

What’s also discussed? Sharing self-injury methods, how to hide it

Self-injury online: YouTube

Lewis et al., 2011

Over 5,000 videos

Highly Viewed

Various forms of video content

We examined the top 100 (based on views)

Over 2 million at the time of analysis

FavourablyViewed

Over 12,000 “favorites”Average rating: 4.6 out of 5

Self-injury online: YouTube

Lewis et al., 2011

50 Character Videos

28% had in-action self-injury (mostly cutting)

50 Non-character Videos

Over 90% had graphic self-injury photographs (mostly cutting)

Most common video

themes/tonesEducational/Informative &

Melancholic (followed by Hopeful)

Self-injury online: Yahoo! Answers

Lewis et al. under review

Yahoo Answers!Most popular Q&A Website online

Functions like an e-community

Questions examined by self-injury disclosure status:

Disclosure: Sought validation/acceptance, concerns re: scars

No disclosure: Asked general questions, how to help others

Self-injury online: Yahoo! Answers

Lewis et al., under review

Do people actually get validation in this e-community?

Sometimes…But not always…

Most self-injury questions are not questions per se

Most youth/young adults seek acceptance & validation

Risks & Benefits of self-injury e-content

Lewis & Baker in press; Lewis et al. under review; Lewis et al., 2011; Whitlock et al., 2006

Key BenefitsDecreased isolation, acceptance, validation & support from others

(but NOT in all forums)

Key RisksTriggering content,

normalization/reinforcement of self-injury, thwarted help-seeking, encouraging self-

injury, etc.

WE HAVE AN OPPORTUNITY HERE…

What can we do?

Enhance your self-injury literacy

www.cares.psy.uoguelph.ca

www.crpsib.com

Identifying self-injury…

Many students will not tell anyone

But, if the do, they are apt to tell a friend (66%)…

Fewer tell a romantic partner (43%)…

Even fewer (less than 30%) tell a teacher or health professional

Know what to look for…

Unexplained scars, cuts, injuries

Difficulty regulating mood

Withdrawal & isolation

Long-sleeves, covering limbs in warm weather

Significant mood changes

Changes in academics, socially

High self-criticism

Finding razor blades, sharps

Know how to discuss self-injury…

It’s not just what you say

It’s how you say it

Talking to students about self-injury

Approaches that do NOT work:1.Intense concern/effusive support2.Anguish/fear3.Recoil/shock/avoidance4.Condemnation & threats

Interpersonal style is highly important…

Klonksy & Lewis, 2010; Klonsky & Weinberg, 2009; Walsh, 2006, 2007

A calm, empathic stylewith a respectful curiosity

What does work….

Klonksy & Lewis, 2010; Klonsky & Weinberg, 2009; Walsh, 2006, 2007

Use their ‘self-injury language’

Talking to students about self-injury

Talking to students who self-injureDo Don’t

Be calm and ‘matter of fact’ when a student talks to you about it; really listen and attend to their feelings

Minimize or say it’s just for attention or that it’s a teen fad. It is a sign of serious difficulty with coping.

Have the discussion in private; be respectfully curious.

Avoid discussions of exactly what they do when they self-injure

Limit the discussion to understanding that NSSI represents difficulty with coping and need to seek help.

Do not assume this is the result of abuse or psychiatric illness

If in line with your school board, refer to a designated mental health professional in the school (e.g., guidance counselor, psychologist)

Do not engage in a unmonitored discussions of NSSI in class (be mindful of a contagion effect)

Discussing self-injury: Summary

Be open & understanding

Don’t ignore it

Express concern & to listen…attend to how the student feels

Be mindful of your reaction

Show you want to genuinely understand what’s going on

Encourage, and refer to, professional help

Other issues: reporting…

By talking to teens, you can better understand WHY they self-injure

If they report suicidal thinking or plans immediate action is needed

Do I contact caregivers if a teen is self-injuring?Unclear at this time…varies by school board

Some types of professional help

Gratz & Chapman, 2009; Klonsky & Muehlenkamp, 2007; Muehlenkamp, 2007; Walsh, 2006

Cognitive Behaviour Therapy (CBT)

Promotes realistic (less negative) thought patterns &

Promotes re-engaging in activities, including social activities

Integrates CBT components but also…

Interpersonal effectiveness/communication skills, mindfulness, emotion-regulation skills (including distress tolerance), etc.

Dialectical Behaviour Therapy (DBT)

Emotion Regulation Strategy: Example

Examples of coping strategies:

Mindful/relaxing BreathingPlay some loud musicYogaPhysical Exercise (go for a run!)Writing (e.g., story, poem, letter)Doing artPlaying or listening to musicTalking with othersMANY other techniques

The Stress Bucket

Summarizing what we can do…

Enhance OUR literacy about self-injury

Learn how to respond effectively (be supportive, direct to professional help)

Referring to school’s designated mental health worker

Awareness

Respond

Promote Professional

Help

Thank you

Contact Information

Email: [email protected]