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  • 1. SELF-INJURY BEHAVIOUR IN YOUTH: ISSUES AND STRATEGIESSelf-injury can be difficult for loved ones and people in the helping field to understand.This workshop will assist participants in understanding the experience and motivations ofadolescents who intentionally injure themselves. In addition, the course will providepractical strategies for working with youth struggling with this complex issue. Participantswill leave this workshop with increased insight regarding self-injury behaviour in youthand direction for effective interventions.This training material was developed by Kimberly R.W. Enns, MSW, RSW, Trainer andConsultant with CTRI Inc. Self-Injury Behaviour in Youth: Issues and Strategies © 2010 CTRI Crisis & Trauma Resource Institute Inc. & Kimberly R.W. Enns, MSW, RSWAll rights reserved. No part of this publication may be reproduced, stored in a retrieval system, ortransmitted, in any form or by any means, electronic, mechanical, photocopying, recording orotherwise, without the prior written permission of CTRI Crisis & Trauma Resource Institute Inc.DisclaimerAll information provided in or throughout this course, manuals and/or training is for educationaland informational purposes only. It is not intended to provide individual counselling or advice andshould not be relied upon for such purposes. You should assess whether you require additionalinformation and, where appropriate, seek independent professional advice. Although KimberlyR.W. Enns, MSW, RSW and the Crisis & Trauma Resource Institute Inc. believe that theinformation is accurate and reliable when it is presented, we do not guarantee that theinformation will always be accurate or current. We and any of our employees, directors,shareholders, officers, agents, affiliates, licensors or suppliers are not legally liable to any personfor damages arising out of or related to the use or application of the contents of this course,manual, and/or training and the information contained within them. You agree at all times toindemnify, defend and hold harmless us of all actions, proceedings, costs, claims, damages,demands, liabilities and expenses whatsoever (including legal and other fees and disbursements)sustained, incurred or paid by us directly or indirectly in respect of the use or application of thecontents of this course, manual, and/or training and the information.
  • 2. DEFINITIONSSelf-Injury:Self-injury is deliberate, self-effected bodily harm of a socially unacceptable nature, donewithout suicidal intent and carried out to reduce psychological distress.  Deliberate: _______________________________________________________  Self-effected: _____________________________________________________  Bodily harm: ______________________________________________________  Socially unacceptable: ______________________________________________  Without suicidal intent: ______________________________________________  Reduces psychological distress: ______________________________________Common Terms: Problematic Terms:Self-harm Self-mutilationSelf-injury Suicidal gestureNon-suicidal self-injury Para-suicide behaviourBody Modification:  Permanent or semi-permanent altering of the body for non-medical reasons.  Includes professional tattoos, body piercings, brandings, scarification, plastic surgery.  Distinguished from self-injury because the tissue damage is viewed as symbolically meaningful, beauty enhancing, as a form of self-expression or done for religious or cultural reasons.  Generally not about reducing emotional distress.  Widely accepted in many social contexts. © CTRI Crisis & Trauma Resource Institute Inc. 2
  • 3. CATEGORIES OF SELF-INJURY BEHAVIOURSDIRECT SELF-INJURYArmando Favazza (1998) developed the following system of categorizing direct self-injury:Stereotypic Self-Injury  Repetitive, rhythmic, monotonous, self-stimulating behaviours (head-banging, skin-picking, self-biting).  Often a result of a biological/sensory drive without particular emotional meaning.  Usually associated with a specific syndrome diagnosed in infancy or early childhood (Autism, Tourette Syndrome).Major Self-Injury  Dramatic acts that cause significant tissue damage (amputation, castration, bone breaking, eye removal).  Rare, tends to be a single, isolated event.  Occurs most often when a person is not in touch with reality (drug-induced or psychotic state, i.e., schizophrenia).Compulsive Self-Injury  Repetitive, compulsive, habit-driven behaviours (hair-pulling, skin-picking, nail- biting, obsessive hand-washing).  May not be under a person’s conscious control.  Usually associated with obsessive-compulsive disorder, trichotillomania, body dysmorphic disorder.  Only considered to be a disorder if the behaviour interferes with the person’s ability to participate in life on a daily basis.Impulsive Self-Injury (Common Self-Injury)  Direct, intentional, intent is unambiguous.  Psychologically motivated (i.e., as a means to cope with emotional pain).  Common self-injury includes but is not limited to: Scratching Interfering with wound healing Cutting Carving Burning Hitting © CTRI Crisis & Trauma Resource Institute Inc. 3
  • 4. CATEGORIES OF SELF-INJURY BEHAVIOURSINDIRECT SELF-INJURYWith indirect self-injury the harm is accumulative; there is generally not immediate tissuedamage. There is a tendency for individuals to deny any harmful impacts as somebehaviours may be culturally sanctioned (smoking, drinking, over-eating).Substance Misuse  Alcohol misuse  Illicit drug use  Use of inhalantsEating Disordered Behaviour  Anorexia  Bulimia  Binge-eatingRisk-Taking Behaviour  Physical  Sexual  SituationalCOMPONENTS OF ALL SELF-INJURY BEHAVIOURS  Direct or indirect: How intentional is the self-injury?  Lethality: How likely is death in the near future as a result of the self-injury?  Repetition: Is the act done once or repeated frequently over a period of time? Multiple episodes (frequent drug overdose) High lethality Single episode (jumping from a height)Direct Multiple episodes (common self-injury i.e., cutting) Low lethality Single episode (self-inflicted burn) Multiple episodes (advanced anorexia) High lethality Single episode (drinking and driving)Indirect Multiple episodes (smoking, drinking alcohol) Low lethality Single episode (refusal of medication) © CTRI Crisis & Trauma Resource Institute Inc. 4
  • 5. DISTINGUISHING SUICIDE ATTEMPTS FROM SELF-INJURY There is often an assumption that self-injury is a suicide attempt. It is important to understand that common self-injury is rarely about taking one’s life, but over time can become a risk factor for suicide. Some comparisons follow: SUICIDE ATTEMPT SELF-INJURYIntent is to end all feeling; escape life Intent is to feel better by obtaining relief from intense emotions or from numbnessSerious physical damage, lethal means used Modest physical damage, non-lethal means usedRarely chronic, one method used Frequently chronic, several methods used over timeSense of hopelessness and helplessness; Some sense of control: there is an option forsuicide is seen as the only way out managing emotionsNo decrease in discomfort following the act Rapid decrease in discomfort and return to usual affectCentral issue: Central issue:Depression/rage/grief regarding inescapable a) Body alienation/numbness orpain b) Emotional vulnerability, inadequate self- soothing skills, peer influences that endorse self-(Adapted from Walsh, 2006) injury Cautionary Notes:  Studies indicate that many individuals engage in self-injury as well as suicide attempts at some point in their lives (Nixon & Heath, Eds. 2009).  Self-injury is considered a risk factor for suicide.  Damage from self-injury may escalate as a person needs more to obtain the same effect.  Damage can be more serious than intended, such as cutting into an artery and being unable to stop the bleeding.  Suicide risk assessment is important. © CTRI Crisis & Trauma Resource Institute Inc. 5
  • 6. WHAT CAUSES SELF-INJURY?The definitive causes of self-injury have not been pinpointed, though researchers agreethat biology, personality and childhood environment all play a role.BIOLOGYSerotonin Theory:  Serotonin is a neurotransmitter that regulates mood, aggression, temperature, appetite, sleep and sex drive.  Some research indicates that people who self-injure may have less serotonin activity than people who don’t self-injure.  Low serotonin activity is associated with negative mood, anxiety, diminished impulse control and aggression to self.Opiate/Endorphin Theory:  Opiates/endorphins are neurotransmitters related to pain relief and feelings of well-being.  One theory is that people who self-injure have overly active opioid systems and experience a large burst of opioid activity when they are injured.  This results in significant pleasure/relief from self-injury as well as above average pain tolerance.PERSONALITY  Some research suggests that certain personality traits predispose people to self- injure.  Impulsivity: difficulty delaying gratification.  Neuroticism: the tendency to experience strong, negative emotions.  Perfectionistic tendencies. © CTRI Crisis & Trauma Resource Institute Inc. 6
  • 7. WHAT CAUSES SELF-INJURYCHILDHOOD ENVIRONMENT  Approximately 50% of individuals who self-injure were abused as children (Gratz & Chapman, 2009).  An invalidating environment (child’s emotional experiences are disregarded) can make one more vulnerable to self-injury.  Poor emotional connection or bond with caregivers.  Harsh punishment (may self-injure in order to continue punishing self).BIOSOCIAL THEORY (Linehan, 1993)  Emotion dysregulation is viewed as the result of both one’s disposition and the environment in which one exists.  Emotional vulnerability refers to being highly sensitive and reactive with poor ability to modulate the resulting strong emotions.  An invalidating environment fails to teach a child to trust and learn to modulate his or her own emotional experiences.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Risk Factors  Self-injury behaviour in one’s family or peer group  Symptoms of depression and/or anxiety  Low self-esteem  Emotion dysregulation  Problems with substance abuse and/or eating disorders  Adverse childhood environmentProtective Factors  Effective management of negative emotions  Family and social support (Nixon & Heath, Eds. 2009) © CTRI Crisis & Trauma Resource Institute Inc. 7
  • 8. INCREASED PREVALENCE OF SELF-INJURYThere seems to be solid evidence that self-injury is not merely becoming more visible butactually more prevalent. Many have speculated as to the social influences that mayspeak to the increase:Family Breakdown  Rise in divorce rates and single parent families.  Children/adolescents are spending more time alone - parents may not be available for emotional support or to teach self-soothing skills.  Youth are subsequently receiving more information regarding emotion regulation from each other.Community/Cultural Breakdown  Loss of connection: people and relationships are transient.  Extended community (family, friends, neighbours) not as available to support one another.  Loss of cultural and traditional values, knowledge, language.Pressure to Excel  Pressure to outperform peers in academics, athletics, etc.  Busy, highly stressful lifestyles, pressure to ”do it all.”  Alternatively, some families cannot afford to enrol their children in extra-curricular activities, or the community has limited options.__________________________________________________________________________________________________________________________________________________________________________________________________________________ © CTRI Crisis & Trauma Resource Institute Inc. 8
  • 9. INCREASED PREVALENCE OF SELF-INJURYTechnology  Mobile phones, texting, instant messaging and social networking sites (Facebook, Twitter, Myspace, etc.) have dramatically altered the way people interact.  Many adolescents have a mobile phone, TV, MP3 player, laptop or tablet, which may serve to decrease face to face contact with others.  Healthy development of emotion regulation skills is being impacted by technology.Media Influences  Emphasis on products/medication to achieve desired mood (no need to tolerate any discomfort, outside agent is readily available).  Many websites, chat rooms, television shows, movies and music videos feature or even promote self-injury.  People prominent in the media report self-injuring (i.e., Angelina Jolie, Johnny Depp, Marilyn Manson).Body Image and Sexuality  Intimate relationships are being entered into at an earlier age.  May result in pressure and emotional intensity for which youth are not ready.  Young people are exposed to unattainable body ideals; can lead to obsession with physical appearance and self-loathing when ideals cannot be met.Peer Influences  Adolescents may seek refuge in a peer group that engages in, admires and thereby reinforces self-injury.  Youth may wear their self-injury scars as badges of honour representing suffering, tolerance of pain or bravery.  Those who self-injure tend to cluster together as there is mutual understanding and reduced fear of rejection.__________________________________________________________________________________________________________________________________________________________________________________________________________________ © CTRI Crisis & Trauma Resource Institute Inc. 9
  • 10. FUNCTIONS OF SELF-INJURYBelow are some of the most common reasons people give for harming themselves.To Feel Better  Many individuals report feeling rapid relief from emotional distress upon engaging in self-injury.  The physical pain of self-injury may be a distraction from emotional pain.  For some, an extreme action like self-injury seems to be the best way to express an intense emotional experience.  Self-injury may be a means of releasing built-up emotions.To Get a Rush  Self-injury causes endorphins to be secreted into the bloodstream.  For some individuals, this produces a natural high or a rush that can be invigorating and addictive.To End Dissociation or Emotional Numbness  Dissociation refers to feeling disconnected from the present moment, one’s body or one`s surroundings.  Dissociation is sometimes self-preserving as it can allow one to temporarily avoid or escape emotional pain, but it can also become automatic and uncomfortable.  Self-injury may be used as a means of relieving this state and reconnecting to the present moment.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ © CTRI Crisis & Trauma Resource Institute Inc. 10
  • 11. FUNCTIONS OF SELF-INJURYTo Punish Oneself  Some individuals come from environments in which messages of worthlessness are constantly received. Self-injury may be an expression of self-loathing.  Other people express feelings of intense guilt and shame; they may blame themselves for problems or past trauma.  Self-punishment through self-injury may absolve one of some of these feelings or be viewed as a form of repentance from sin.To Communicate to Others  Those who self-injure may have difficulty opening up to others or may feel invalidated when they try to do so.  Self-injury communicates the extent of one’s emotional pain without the need to use language – may be a cry for help.  Important not to dismiss as attention-seeking or manipulative behaviour.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How does an individual start self-injuring?  Often begins on an impulse.  May start because of others in life who are self-injuring.  May learn about self-injury through TV shows, movies, music videos, chat rooms.  In some cases may be accidental: injury occurs and the individual feels surprisingly soothed.  Extreme agitation/rage often results in a desire to respond physically – pattern of self-soothing through aggressive acts may develop. © CTRI Crisis & Trauma Resource Institute Inc. 11
  • 12. PROBLEMATIC REACTIONSCaregivers, upon discovering that a young person is self-injuring, may understandablybecome anxious and fearful for that person’s safety. Extreme reactions as well aschoosing to ignore the behaviour may serve to trigger or maintain the self-injury.  Reaction may be one of anger (i.e., lectures) or disgust (i.e., recoil).  The self-injury may be considered “just attention seeking” or a form of manipulation and therefore ignored.  Behaviour is assumed to be suicidal and youth is placed on suicide watch.  Caregiver issues ultimatums.  Youth’s bedroom and belongings are regularly searched for self-injuring tools.  Caregiver worries that every word or action may prompt a self-injuring incident.  Caregiver does not respond at all to the behaviour due to personal discomfort.  Behaviour is viewed as a phase that will disappear on its own.  Caregiver’s primary concern is with how the self-injury reflects on them.Why it is Important to Respond:  Some young people use destructive behaviours in an attempt to create relationship, or involvement from adults; may have learned that the only way to gain this involvement is through being in crisis.  Some individuals display their injuries/make no attempt to hide them: likely putting pain on display in the hopes that someone will notice there is a problem.  Self-injury is the perfect vehicle to express the need for help without ever having to approach anyone about it.  When consistently ignored, self-injury is likely to escalate so that there is no possibility of anyone ignoring it.  Early detection and intervention is critical. © CTRI Crisis & Trauma Resource Institute Inc. 12
  • 13. SELF-INJURY WARNING SIGNSIndividuals who self-injure are often very good at hiding it from others. They may feelshame and fear judgemental reactions. Sometimes a self-injurer will recognize that theyhave a serious problem and seek help, but more often parents/caregivers/friends willdetect that something is wrong.Warning Signs  Frequent injuries (i.e., cuts, bruises, burns) with suspicious explanations.  Wearing pants and long sleeves in warm weather (to cover injuries).  Wearing bangles, bracelets and wristbands (to cover injuries).  Low self-esteem.  Difficulty handling emotions, easily overwhelmed.  Extremely sensitive to rejection.  Self-defeating comments and attitude.  Extreme emotional ups and downs (due to the cycle of self-injury).  Difficulty functioning at school, work or home.  Relationship problems.  Avoiding sports or other activities that would require showing more of one’s body.  The presence of behaviours that often accompany self-injury: eating disorders, drug/alcohol misuse, excessive risk-taking.  Discovery of tools used for self-injury (broken disposable razors, lighters, un-bent paper clips).  Bloodied wads of tissue or toilet paper, blood on towels or clothing.  First aid supplies being used quickly.  Rubbing arms, especially wrists, through sleeves (cuts often itch while they are healing).  Withdrawing from activities once enjoyed.  Increased time alone  Increased time with peers who self-injure. © CTRI Crisis & Trauma Resource Institute Inc. 13
  • 14. THE CYCLE OF SELF-INJURY Trigger - i.e., Interpersonal conflict, social isolation, academic demands, etc. - Reaction - self-defeating thoughts Escalating Emotional Tension - Initial calm and euphoria replaced with feelings of - Distorted, negative thinking shame or guilt occurs, leading to overwhelming emotions- Communication with others may occur - Individual starts to feel agitated/ready to explode Return to Normalcy Panic - Sense of calm and relief/ - Individual experiences anfeeling more alive and better irresistible urge to self-injure able to function Self-Injury - Severe tension is rapidly reduced - Individual may or may not feel pain during act (Adapted from Sutton, 2005) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ © CTRI Crisis & Trauma Resource Institute Inc. 14
  • 15. INITIAL RESPONSEThe strategies outlined in this manual follow the principles of cognitive behaviour therapyand dialectical behaviour therapy, common approaches for working with self-injuringadolescents. Successful intervention often involves active participation from the family,the individual’s social network and professionals from the larger system.The initial response to an individual regarding their self-injuring behaviour can havesignificant long-term effects. As self-injury behaviour runs counter to humanexpectations regarding self-protection, normal reactions may include fear, recoil, shock,anger and hysteria. These reactions may prevent an individual from seeking help.Others may respond with an outpouring of empathy, which may inadvertently reinforcethe behaviour. When working with individuals who self-injure:  Do not dismiss or minimize the self-injury.  Validate the individual regarding the intense emotions that have led to self-injury.  Avoid reactions of judgement, recoil or shock.  Avoid dramatic outpourings of concern and support.  Calmly assist in obtaining medical attention if necessary.  Do not insist on immediate abstinence from self-injury.  Manner should be matter-of-fact, calm and compassionate.  Convey the message that many have overcome self-injury and they can too.  Remember that a strong therapeutic alliance is critical to the process of overcoming self-injury.  Be cognizant of the individual’s readiness for change. (Appendix p.51)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ © CTRI Crisis & Trauma Resource Institute Inc. 15
  • 16. SELF-INJURY CONTAGIONSelf-injury contagion refers to a statistically significant cluster of self-injury behaviouroccurring within a group. Studies have shown that self-injury contagion is particularlyprevalent amongst adolescents. There is a rising trend for youth to discuss self-injuryonline and to form cutting clubs within their schools, thereby triggering the behaviour ineach other. In some cases, youth self-injure in one another’s presence, may share toolsor even take turns injuring one another.Why Does Contagion Occur?  Many youth are introduced to self-injury through a friend.  Self-injury may produce feelings of cohesiveness within a group.  Self-injury may be encouraged, admired and thereby reinforced within a social context.  Self-injury is a powerful form of communication.  The behaviour may be inadvertently reinforced by the adult response.Preventing / Responding to Contagion  Reduce communication regarding self-injury among members of a peer group: Adolescents may compete with each other regarding the extent of self-injury. Some youth post pictures and vivid descriptions regarding their self-injury online.  Reduce the display of recent self-injury wounds by requiring that appropriate, covering clothing be worn.  Caregivers must strive to react to self-injury behaviour in a calm manner, recognizing the seriousness of the issue but not inadvertently increasing its appeal through reactions of hysteria or an outpouring of empathy.  Within a given community, self-injury should generally be treated through individualized methods, rather than in groups. © CTRI Crisis & Trauma Resource Institute Inc. 16
  • 17. RESOURCESLITERATUREBarnett Veague, H. (2008). Cutting and self-harm. New York, NY: Chelsea House Publishers.Beck, J.S. (1995). Cognitive therapy, basics and beyond. New York, NY: Guilford Press.Bowman, S., Randall, K. (2006). See my pain! Creative strategies and activities for helping young people who self-injure. Chapin, SC: YouthLight, Inc.Conterio, K., Kingson Bloom, J. & Lader, W. (1998). Bodily harm: The breakthrough healing program for self-injurers. New York, NY: Hyperion Press.Gratz, K.L. & Chapman, A.L. (2009). Freedom from self-harm: Overcoming self-injury with skills from DBT and other treatments. Oakland, CA: New Harbinger Publications, Inc.Hardy, K.V. & Laszloffy, T.A. (2005). Teens who hurt: Clinical interventions to break the cycle of adolescent violence. New York, NY: The Guilford Press.Hollander, M. (2008). Helping teens who cut. New York, NY: The Guilford Press.Kabat-Zinn, J. (2007). Mindfulness for beginners. Louisville, CO: Sounds True, Inc.Kettlewell, C. (1999). Skin game: A cutter’s memoir. New York, NY: St. Martin’s Press.Leatham, V. (2006). Bloodletting: A memoir of secrets, self-harm and survival. Oakland, CA: New Harbinger Publications, Inc.Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press.Walsh, B.W. (2005). Treating self-injury: A practical guide. New York, NY: The Guilford Press.RECOMMENDED FORUMS FOR SELF-INJURERSThe following forums are carefully moderated for triggering content and any form of self-harmpromotion. Their focus is to support individuals in their journey towards healing and wellness.www.dailystrength.org www.recoveryourlife.comwww.selfinjury.com/blog/ Yahoo groups: Nofear-SAFE_approved © CTRI Crisis & Trauma Resource Institute Inc. 17
  • 18. PHONE –DISTRESS LINESAlbertaHealthLink 1-866-408 5465SaskatchewanHealthline 1-877-800-0002ManitobaHealthlinks 1-888-315 9257NunavutKamatsiaqtut Help Line (800) 265 3333YukonMental Health Services(867) 667 8346NWTMental Health and Addiction Services Specialist (867) 873 7033NWT Helpline 1-800-661 0844(7-11 pm)Information, Support, and ReferralNationalKids Help Phone 1-800-668-68681-800-DONT-CUTWEBSITESLifesigns: Self Injury Guidance and Network Support: www.lifesigns.org.ukPublic Health Agency of Canada: www.canadian-health-network.caS.A.F.E. (Self-Abuse Finally Ends) Alternatives: www.selfinjury.comSelf-Injury: www.mirror-mirror.org/selfinj.htmSelf-Injury and Related Issues: www.siari.co.ukSuicide and Mental Health Association International: www.suicideandmentalhealthassociationinternational.orgSecret Shame: Self-Injury Information and Support: crystal.palace.net/~llama/psych/Youth Noise: www.youthnoise.comFirstSigns Voluntary Organisation: www.selfinjury.org.uk/ © CTRI Crisis & Trauma Resource Institute Inc. 18