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Understanding Self-Injury

1.WHO SELF INJURES?2. WHY DO THEY DO IT?3. WHAT IT IS AND IS NOT.4. HOW CAN WE HELP?

Self Injury

Caroline Kettlewell from Skin Games

“I needed to cut the way your lungs scream for air when you swim the length of the pool underwater in one breath. It was a craving so organic it seemed to have risen from my skin itself.”

Self-Injury Terms

Self Inflicted Violence

Cutting

Self Harm

Self Mutilation

SI BehaviorsCuttingScratching Abrading BurningSome forms of hair pullingBitingInserting foreign objects into the bodyInterference with wound healingIngesting toxins

Warning signs

Unexplained frequent cuts or burnsWearing long sleeves or pants in warm

weatherAvoiding swimming pools or the beachWearing thick bracelets to cover wristsHaving sharp objects in purse, book bag,

or bedroomDifficulty expressing feelingsWithdrawal from close relationships

What is the Definition

Self injury is the intentional harm of one’s own body without conscious suicidal intent. (Aldeman, 1998, Favazza, 1998, van der Kolk, et al., 1991)

What Self Injury is NOT

It is not a suicide attempt (attempting to feel better, not escape all feelings)

It is not usually attention seeking

It is not a danger signal to others

NOT SUICIDAL BEHAVIOR

“…self-mutilation is distinct from suicide…A basic understanding is that a person who truly attempts suicide seeks to end all feelings where as a person who self-mutilates seeks to feel better.” (Favazza, 1998)

Intention-does not intend to die as a result of his/her acts. Intends to live.

Who Self-Injures

Roughly 2% (1-4%) of the population. In some studies reported as high as 8 million Americans self-mutilate.

30 times the rate of suicide attempts 140 times the rate of completed suicides May also suffer from eating disorders 90% who cut began as teenagers

Typical profileFemaleMid 20’s to early 30’sBegan cutting as a teenMiddle to upper classIntelligent, well

educatedPerfectionist

Profile (cont)Males and femalesAll races and socio-economic levels

Ages 15-50’sNot easily identifiable

Characteristics

are often depressed, feel powerless or anxious

have low self esteem /negative body image

have difficulty expressing their emotions verbally

experience difficulty with relationships aim for perfectionoften have negative body imagelack impulse control/suppressed angerdo not have a repertoire of coping

skillsmay have serotonin dysfunction possible trauma

Abuse?

Many who self-injure did not suffer childhood abuse (Zweg-Frank, et.al, 1995, Brodsky, et. al., 1998)

50-60% suffered childhood abuse or trauma. That means that 40-50% did not (Favazza,1998)

Then Why?

Invalidating environments (Lineham, 1993) Expression of private experiences and feelings

are not validated Feelings are trivialized, punished or ignored Experience of painful emotions are disregarded. Child’s interpretation of his or her behavior is

dismissed

In their own words . . .

“There are times when I hurt too deep for tears, so I cut and it lets out some of the hurt. It’s like when you see the blood flowing out, the pain and fear are flowing with it.”

“Watching the blood flow out makes me feel clean, purified. It feels like something bad or dirty is leaving with the blood.”

In their own words . . .

“The stopped voice becomes a hand lifting knife, razor, broken glass to cut, burn, scrape, pop, gouge. The skin erupts in a mouth, tongue less, toothless. A voice drips out, liquid…a voice sears itself for a moment, in the flesh. This is a voice emerging on the skin, a mouth appearing on the skin. The body which could not be air on the larynx becomes the stroke of a razor on the breastbone or of a red-hot-knife-tip upon the wrist…” .

Janice McLane (1996)

Why do they harm themselves?

To release intense feelingsThe physical pain may be easier to deal with than the emotional pain

To feel real, aliveTo exert some controlActing out self punishment

Cycle of Cutting

Shame, guilt,

remorse, disgust

Mounting anxiety, anger or self hatred, alienation

Disassociation

Cutting

Relief

Into the Void

Panic

Muller 2005

In own words . . .

“

“It’s like opening up a safety valve or letting steam out of a covered pot.”

“Sometimes I cut just to make myself feel something because I am just totally numb.”

(In Strong, 1998, p.7)

Why Self-Mutliate?

“I felt like I was isolated from the world, dead, with no emotions at all. The blood told me I was alive, that I could feel…Also I couldn’t cry, and bleeding was a different form of crying.”

(Lindsay in Strong, p.57)

DSM IV Classification

Some mental health professionals are advocating for self injury to be listed as a separate diagnosis

Currently listed as a symptom associated with a number of mental health disorders

SI is often associated with:

Borderline Personality DisorderObsessive-Compulsive DisorderPost-Traumatic Stress DisorderDissociative Identity DisorderEating DisordersSubstance AbuseDepression

DIAGNOSIS (Ferreira de Castro, et.al., 1998)

Major Depression 14% 56%Alcohol Dependence 16% 26%

Schizophrenia 2% 9%

Dysthymia 12% 7%

Adjustment disorder with depressed mood

24% 6%

Self-Injure Suicide Attempt

Therapeutic Goals

Encourage communication about self-injury and relevant aspects of the child’s life.

Improve the quality of client’s life as it relates to self-injury.

Explore themes of guilt and shame.Diminish use of self-injury as the coping

skill when client desires to make changes. (Conners, Rubin, et, al,2002).

Helping: What to Do (Alderman, 1997)

Learn about self-injury.Talk about SI. Ask about it.Be supportive. Show you care.Acknowledge the effort to cope with very

difficult emotionsSet limits Be available, but refer when appropriateDon’t discourage self-injuryRecognize the severity of the distress

What Not to Do

Be afraid to ask the question, “Do you self-injure?”

Make eliminating the behavior the primary goalMake a safety contract or use contracts as a

reward or punishmentVisibly monitor their injuriesMake him or her feel ashamed or guilty about

the behavior

“This is yet another secret I must hold to myself because my therapist has given me an ultimatum, either no more hurting myself or we will have to discontinue our therapy. So a little distance comes between us now, a secret that hold great importance which we could both learn from, if I was able to tell her…JML

Interrupting the Cycle

Dispute irrational thoughts, feelings

Triggering event Unbearable tension, anxietyDissociationSelf injuryRelapse

Expressive Arts

Journals

Poetry

Music

Art

Respond to the following statements by writing “A” for “agree” if you mostly agree with the statement or “D” for “disagree” if you mostly disagree. Be ready to explain your responses.

___Self-injurers are survivors.___Self-injurers are weak people.___Self-injurers are harming themselves to get attention.___Self-injurers are perfectionists. ___Self-injury is a type of suicidal behavior.___Self-injurers are proud of their scars.___Self-injury helps people cope.___Self-injurers are more sensitive than most other people.

Muller 2006

Self-Injury Group

Self-Injury

If my wound could talk it would say____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Muller 2006

Taking Care of Yourself

Monitor your own horror and confusion

Broaden your perspective past the behavior to the intent behind it

Seek consultation Get support for yourself

Care and Concern

The capacity to derive comfort from another is the single biggest predictor of whether traumatized patients are able to give up their self-destructive habits. (van der Kolk)

Care and Concern

The development of a safe and trusting relationship is vital for the child to learn to sooth and care for him or herself in a healthy manner by internalizing their therapist’s care and concern. (Strong, 1988)

Care and Concern

“_____ was the first to acknowledge that maybe I was in pain, as opposed to ‘doing it for attention’ . This affirmation of my inner pain was a healing force. “ Shelley

10

Discussion

Why the upsurge in self-injurious behavior?

Students who look for fist fights?

Tattoos and piercing?

Addictive?

References:

References: lmuller@bcps.orgmmathews@bcps.orghttp://www.helpguide.org/mental/self_injury.h

tm

http://vivianpencz.wordpress.com/2012/01/11/breathing-while-drowning-youth-who-self-harm/

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