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Welfare Guardian

Responding to Self-harm in Schools

Dr Erin BoweClinical Psychologist

Welfare Guardian

Current and preferred term is ‘nonsuicidal self-injury’ (NSSI)

‘self-harm’ or ‘self-injury’ is easier for everyday speak

Regional differences in terms Self-poisoning has different motivations & lethality

Nomenclature

To better equip yourself and staff to deal with common incidents

To improve skills in determining appropriate level of response for a range of possible crisis events

To learn tricks in using principles of calm, factual and non-emotive language

To have a clearer understanding of how to seek further advice and support for yourself, staff, students and parents

Introduction: Goals of session

Understanding self-harm behaviours Responding to crisis Communication skills Special considerations within school

settings Self-care, supervision and referral

Overview

Pre and post-workshop reflection

0= NOT AT ALL CONFIDENT 1= SOMEWHAT CONFIDENT 2= CONFIDENT

 How confident do you feel: Working with students who have engaged in self-harm? Being able to differentiate a crisis from more intermediate

and mild incidents? Understanding best-practice treatment approaches for self-

harm? That you could handle a crisis?

Deliberate cutting, burning, scratching with the intent of causing bodily tissue

For the purpose of affect regulation (to feel ‘better’, ‘calmer’ or just ‘different’)

Almost always non-suicidal Usually repetitious Usually associated with powerful, rewarding

psychophysiological responses A maladaptive, but effective coping strategy

Self-harm is

A suicide attempt Parasuicide (behaviour which mimics suicide attempt) (Sub)culturally accepted body modification Stereotypic/compulsive self-harm (neurological basis) Psychotic self-harm (e.g., self-amputations) Indirect or cumulative bodily damage (eating disorder,

substance use, or risky stunts)

Self-harm in this context is not to be confused with:

Predisposing factors

Stressful events Self-harm specific factors

Self-harm outcome=+x

Cognitive-emotional-biological vulnerability• High emotion reactivity• Emotional numbing• Poor distress tolerance• Thought suppression• Rumination

Social vulnerability• Early

abuse/maltreatment• Familial hostility/criticism• Poor communication

skills• Poor problem solving

• Stressful event

Triggers over or under

Arousal (automatic

Functions) OR• Event presents high

Social demands

(Social function)

Self-harm

• High self-criticism

• Modelling of peers/media

• Need for strong/honest signal

Regulation of emotional experience

Regulation of social situation

Psychological model of the development and maintenance of self-harm (Nock & Cha, 2009)

 Appears to be 3 possible pathways

1. ‘One-off’, non-rewarding response (about 30%)2. Tension reduction* response (about 70% will repeat)3. Atypical, excitation** response (seen in Borderline PD; or

a least a subtype of BPD, unknown % but likely very low)

*Well established in literature**Less well established in literature, still speculative

Who does it?

Increased levels of negative emotions

Depersonalisation occurs

Individual reaches a level they are no longer able to tolerate

Engage in act of self-harm with little/no pain (injury opens access to the brain’s 24 hour pharmacy of endorphins &

opiates)

Repersonalisation occurs (negative reinforcing property)

‘Typical’ response: tension reduction model

Poor coping skills Low tolerance for negative emotions Impulsive, want instant relief Perceived lack of control High levels of dissociation Often unable to utilise problem solving once

distress reaches a certain threshold

Typical response

Experience interpersonal conflict, rejection, separation, anger, self-hatred, depression, loneliness and abandonment

Experiences may be real or imagined As self-harm become habitual, cutting is

often precipitated by more minor events

Typical response

Most people have a hard time explaining “why” they cut (content)

But can describe what, where, how led to the behaviour (process)

Does the “why?” change anything? Fundamentally, self-harm is a maladaptive coping

strategy It’s an attempt to communicate distress Counsellors should try to prioritize process over

content

Faulty Assumptions- “why?”

You or another student finds someone cutting in private (e.g., in bathroom)

1. Respond neutrally & model calm posture (think: relax jaw, relax hands, relax shoulders)

2. Offer support (get band aids, offer a chance to talk about it) without being reactive

3. Use empathic statements, focus on immediacy

Crisis #1

4. Immediacy- ask the student what s/he wants to happen next an offer 2-3 options.5. Follow up. Book a time to talk, or talk to the student about referral. 6. Reflect on your own self-care & debriefing needs

Crisis #1 continued

A student or students engage in self-harm in front of others (e.g., in class)

1. Use empathic reminders that (1) it’s ok to be upset, but (2) others are upset by the behaviour.

2. Offer support (bandaids, a chat)3. Offer 2-3 options: 1. clean up & go back to

class, 2. Sit somewhere quiet with a friend until next class, or 3. visit counsellor/debrief with someone

Crisis #2

4. Manage any other students’ distress by acknowledging & validating, but quickly moving forward (give the same options – break, talk, or resume class)5. Follow up. Book a time to talk, or talk to the student about referral. 6. Reflect on your own self-care & debriefing needs.

Crisis #2 continued

A student reveals that s/he has engaged in self-harm (but no current crisis)

1. Simply ask the student what s/he wants to have happen now (talk now, or later?)

2. Make sure a follow up time is booked (preferably by the end of the day)

3. Aim to clarify the intent (“so the cutting was about feeling overwhelmed, but not about taking your life?”)

Non-immediate crisis

4. Encourage parental communication (consider age and mature minor principle if necessary)5. Encourage a referral to an external psychologist (particularly important if the student is not open to parental disclosure)

Non-immediate crisis cont.

No, not unless absolutely necessary Tends to reinforce the behaviour Increases feelings of rejection & isolation

Send students home?

Represents a unique but not unusual occurrence in ‘institutional’ settings (schools, hospitals, prisons)

Contagion effect Important to correct any misinformation and

address ‘us vs. them’ phenomena Work towards strengthening alliance

between parents, adolescents and counsellor

Self-harm in groups & cliques

Can be effective if student has a circle of non self-harming friends

Similarly, older students who have recovered are a strong source of modelling and support

Groups with only people who self-harm need to be selected very carefully, they need to be highly structured and run by an experienced therapist

Addressing the Issue: Groups?

False assumption that all members want to change; or that the motivation for change is stable/consistent

Participant matching issues in school setting Members can often provide false validation rather than

support Extra challenges with personality disorder, trauma, eating

disorder and substance use Risk of re-triggering & re-traumatisation Risk of ‘one-upmanship’ behaviours Biased motivations for participating ‘sharing’ not as effective as structured skill-based groups

Risks with Groups

Immediacy Neutral tone of voice, face and statements Importance of orienting the student to counselling process Try to avoid the temptation to get into lengthy discussions

with students or parents about “why” people self-harm Teach/model skills in emotion identification, labelling and

explaining Focus on the factual information about the mechanics or

the process (i.e., reduces heart rate, body releases natural feel-good opioid hormones)

Communication skills

Crisis management, putting out ‘spot fires’ Educating others, translating knowledge Explain behaviour curve- delay, distract, decide Ongoing motivational interviewing Encourage replacement skills early on, but

acknowledge their limited use & use as a tool for encouraging long-term strategies

Realistic options for school counselling

Anxiety is the biggest block to care Listening your own thoughts, rather than the

students Can’t be present and calm if you’re rehearsing Questioning like a lawyer rather than an

anthropologist When you’re working harder than the client Being impatient or intolerant of silence Mismatching your approach to client’s actual stage

of readiness to change

Road blocks to student care

If ever in doubt, refer out Most self-harm takes 12 mo+ to treat effectively Emphasise confidentiality Validate ambivalence about seeking help & keep

encouraging Achievable goal in short-term for most students is (1)

waiting skills and (2) reducing frequency (rather than cessation)

Referring out

Responding to Crisis flowchart Basic Distraction Techniques Handout for Parents Quick Facts about self-harm Tips and strategies for adolescents Tips and strategies for younger children

Worksheets and Handouts

Self-harm is almost always non-suicidal Maladaptive but effective coping strategy Is a way of communicating distress The psychophysiology of self-harm is very powerful Is incredibly difficult to treat. Follows similar

patterns to other addictive behaviours Addressing motivation to change is crucial first step It must be the individual’s choice to stop, you cannot

make someone stop

Summary

Familiarise self with facts, practice neutral communication

Differentiate immediate crisis from more mild or intermediate events

Consider how to make transition from self-harm incident back to regular activities more seamless

Consider how to tackle cliques (talk to each member one on one to reduce contagion)

Remember to reflect and address own self-care

Summary

0= NOT AT ALL CONFIDENT 1= SOMEWHAT CONFIDENT 2= CONFIDENT

 How confident do you feel: Working with students who have engaged in self-harm? Being able to differentiate a crisis from more intermediate

and mild incidents? Understanding best-practice treatment approaches for self-

harm? That you could handle a crisis?

Post-workshop reflection

This time of year is usually the beginning of ‘peak’ self-harm trends in schools

Do you need further support, coaching or guidance about how to manage self-harm in schools?

Just need someone external to school to bounce ideas off?

Individual supervision via Skype or at our Port Melbourne office is available

Supervision