Self Care Without Injury
Canadian Counselling and Psychotherapy
Association (CCPA) Annual Conference
May 11-14, 2010
Charlottetown, Prince Edward Island
Presented By
Nancy Buzzell, Ph. D., Licensed Psychologist
University of New Brunswick Counselling Services
Sarah Smith, Research Assistant
Mount Allison University
As Laura entered her house she slammed the door behind her. It had been a
bad day, a very bad day. Things at school had been terrible. As Laura locked
the door to her bedroom, she was so angry that her whole body was shaking.
All she wanted to do was cry, but no tears would come. Laura knew what she
needed to do to feel better. She took a small wooden box from under her bed.
Carefully lifting its lid, she removed the contents, a single edged razor blade
and a packet of gauge bandages. Sitting on the carpeted floor, gently rocking
back and forth, she stared at the silver blade in her hand. She needed to do it,
she told herself. It was the only way she could feel better, feel normal again.
Laura felt no pain as she made the first of several cuts on her left forearm. She
watched as the blood spilled from the cuts and dripped down her arm. It felt
warm and soothing on her cold skin. After cutting herself in three or four
places, Laura wiped the blade clean with a piece of gauze and placed it back in
its box. She wrapped her wounds tightly with the bandages, only then feeling
the sting. Although she felt tired and drained, she also felt much better.
Cutting herself had worked, just as it always did.
Alderman, T. (1997). The scarred soul. Oakland, CA: Harbinger Publishers.
Self Injurious Behavior
All behavior involving the deliberate
infliction of direct physical harm to
one’s body without the intent to die.
Simeon, D., & Favazza, A. (2001). Self-Injurious behaviors: Phenomenology and assessment. In
Simeon & E. Hollander (Eds.), Self-injurious behaviors: Assessment and treatment (pp. 1-28).
Washington, DC: American Psychological Association.
Self Injurious Behavior (SIB)
 Breaking bones
 Burning (8%)
 Biting
 Hitting/bruising (3%)
 High risk activity
 Needle sticking








Cutting (86%)
Scratching
Hair pulling
Head Banging
Picking
Skin picking
Starving self
Other (3%)
Gratz, K. L.. (2006). Risk factors for deliberate self-harm among female college students: The role and
interaction of childhood maltreatment, emotional in-expressivity and affect intensity/reactivity. American
Journal of Orthopsychiatry, 76 (20), 238-50.
Historical Trends
 Before 1990: Prevalent among individual
with serious mental health issues and
abuse/trauma backgrounds
 After 1990: Prevalent among school age
children, adolescents & university students
 Rate has risen by 150% over the last 20
years across a broad spectrum of society
Enns, K. (2008). Self injury behaviour in youth: Issues and strategies. Winnipeg, MB: Crisis & Trauma
Resource Institute Inc.
Who Does It Affect?
Percent
Population
21%
ClinicalF/M)
Briere & Gil (1998) **
7%
University
F/M)
Gollust et al (2008)
38%
University
(F/M)
Gratz et al (2002) **
37%
University
(F)
Gratz (2006)
44%
University
(M)
Gratz & Chapman (2007)
13.89% High School (F)
13.9%
Researchers
Ross & Heath (2003)
Community (F) Ross et al (2009)
Rates of SIB are estimated to be between 12%-38%
Meta-analysis: 8 Functions
of Self Injury (Cutting)
 Behavioral or the reinforcement of destructive
behavior & the linking of injury with self care
 Systemic or a way to express dysfunctional family
or environment
 Suicidal or a suicide replacement
 Sexual or a result of conflicts over sexuality &
menarche
Suyemoto, K. L., & MacDonald, M.L. (1995). Self cutting in female adolescents. Psychotherapy:
Theory, Research, Practice, Training. 32(1), 162-171.
Meta-analysis: 8 Functions
of Self Injury (Cutting)
 Expression or a need to express or externalize
overwhelming of anger, anxiety or pain
 Control or an attempt to control affect or need
 Depersonalization or a way to end or cope with not
feeling present & in one’s own body
 Boundaries or an attempt to create distinction
between self & others
Suyemoto, K. L., & MacDonald, M.L. (1995). Self cutting in female adolescents. Psychotherapy:
Theory, Research, Practice, Training. 32(1), 162-171.
General Risk Factors
 Feelings of powerlessness
 Feelings of being alone or isolated
 Difficulty recognizing/communicating feelings
 Few, if any, alternative coping behaviours
 Few self care or self soothing skills
 History of physical, sexual or mental abuse
 A likable, sometimes high achieving person with
other problems.
Levenkron, S. (1997). Cutting: Understanding & overcoming self mutilation.
NY: WW Norton & Company.
Specific Risk Factors
Characteristic
Researchers
Depression and anxiety
Hoff and Muehlenkamp (2009)
Peer invalidation
Adrian (2010)
Family invalidation
Adrian (2010)
Academic difficulties
Mahadevan, Hawton & Casey (2010)
Disordered eating
Ross, Heath & Toste (2009)
History of drug use
Saules, Cranford & Eisenberg (2010)
Sexuality Identity
Saules, Cranford & Eisenberg (2010)
Social Context
Recent research with university students who self-injure
found that:
 43.6% of students reported that their behaviour was
learned socially
 86% of participants knew someone who self injured
 74% had at least one friend who self injured
 65% had talked to their friends about it
 17.4% had engaged in it in front of friends
 4.3% had engaged in it as a group with friends
Heath, N. L., Ross, S., Toste, J. R., Charlebois, A. & Nedecheva, T. (2009) Retrospective
analysis of social factors and non suicidal self-injury among young adults. Canadian
Journal of Behavioral Science, 41, 180-186.
The Dissociation Factor
Dissociative:
Disconnected from parents, others &/or self. Not secretive
about cutting & at times damages self in full view of others.
Attention is gratifying (secondary gain) in it’s own right.
Non-Dissociative:
Physical pain becomes a cure for emotional pain. Usually
starts with feelings of anger, anxiety or panic. Person
“stumbles” upon self injury and discovers it relieves their
emotional state. Instant relief. Endorphin rush.
Levenkron, S. (1997). Cutting: Understanding & overcoming self mutilation. NY: WW Norton & Company.
Often Starts on an Impulse
 May start because of others in life who
are self injuring
 May learn about self injury through tv
shows, music videos, chat rooms
 May be accidental: injury then person felt
soothed
 May be result of extreme agitation/rage &
becomes pattern of self soothing
Enns, K. (2008). Self injury behaviour in youth: Issues and strategies. Winnipeg, MB: Crisis & Trauma
Resource Institute Inc.
Self Assessment Tool
1. If I do this, will it hurt or harm my body? If I answer “no”
would other people agree with me?
2. If I do this, will I need help coping with the repercussions?
Will I need to see a doctor, nurse, counsellor?
3. If I do this, will the people I care about be upset?
Frustrated? Frightened? Appalled?
4. If I do this, will I lose an opportunity to reach my goals in
life? Drop out of school? Miss an important opportunity?
If you answer yes to just one, you are self harming.
Haswell, D., & Graham, M. (2008). 5th Edition. Overcoming self-abuse.
Hamilton, ON: S.A.F.E. in Canada.
Clinical Assessment
 Frequency, duration, severity, medical history
& possible complications
 Reasons or purpose of SIB
 Determining client’s stopping point
 Education about function (both +ve & -ve)
 Providing appropriate alternatives
 Ever thought about suicide?
Wester, K. & Trepal, H. (2005). Working with clients who self injure: Providing alternatives. Journal
of College Counseling, 8, 180-189.
Why People Say It “Works”
 It calms me person down
 It helps me feel more in control
 It makes me feel “alive”
Haswell, D., & Graham, M. (2008). 5th Edition. Overcoming self-abuse.
Hamilton, ON: S.A.F.E. in Canada.
Why We Think It Works
 Expresses feelings
 Releases negative emotions & tension
 Makes emotional pain clearer
 Punishment
 Ends dissociation
 Results in a rush or a high
 Communicates something to other people
Gratz, K. & Chapman, A. (2009). Freedom from Self-Harm. Oakland, CA: New Harbinger Publishers.
How it Works
 Like other injuries, it brings about the
release of endorphins which are natural
pain killers that calm down the central
nervous system.
 It triggers (or ends) dissociation which
is the mind’s way of producing a state of
trance in which emotion & pain can be
disregarded.
Haswell, D., & Graham, M. (2008). 5th Edition. Overcoming self-abuse.
Hamilton, ON: S.A.F.E. in Canada.
Reasons it Doesn’t Work
 Undermines a person’s mental,
physical, social & spiritual well-being
 Does nothing to solve problem(s)
 Offers only temporary relief
 Often followed by guilt & shame
Haswell, D., & Graham, M. (2008). 5th Edition. Overcoming self-abuse.
Hamilton, ON: S.A.F.E. in Canada.
www.safeincanada.org
E
SAFE Scale
F
A
Safe: No trigger
Ascending: Starting to feel
triggered
Feeling: Out of control &
urge to self injury
Extremely unsafe & strong
urge to self injure
S
Trigger
Baseline
Baseline
Self abuse does not allow the person to return to baseline.
Next time person start s off at a higher trigger point.
Addiction Model
Negative Emotions
Alienation, Anger, Depression,
Frustration, Rejection, Sadness
Negative Effects
Tension
Shame, guilt, depression
Inability to control emotions &
thoughts of self injury
Positive Effects
Dissociation
Endorphins present, tension &
negative emotions reduced
Coping mechanism to reduce
tension & later physical pain
Self Injury
Burning, cutting, hitting,
pulling hair, scratching
Alderman, T. (1997). The scarred soul. Oakland, CA: Harbinger Publishers.
Questions We Can Ask
1. Think back to a time when you self injured. List
three of the most intense emotions you had
before you acted.
2. Describe how you felt when you began to think
about hurting yourself. Did your feelings
change as you got closer to injuring yourself?
3. Describe what you went through when you self
injured. Did your feelings change throughout
the process?
Alderman, T. (1997). The scarred soul. Oakland, CA: Harbinger Publishers.
More Questions
4. What happened after you hurt yourself. How did
you feel? Calm? Tired? Peaceful? Anxious?
5. List the ways your self injury contributed to a
feeling of relief. How do you define relief?
6. How long did it take after hurting yourself to feel
bad again?
Alderman, T. (1997). The scarred soul. Oakland, CA: Harbinger Publishers.
How Does it Function
for the Client?
How does it help?
How does not help?
 Makes me feel better
 I have to do more for it to work
 Helps me feel in control
 I feel bad about myself
 Takes my mind off things
 I have to hide the scars

 It upsets my boyfriend


Client’s Self Injury Log
1. Time & date of self injury
2. Situation or trigger
3. Thoughts & feelings before self injury
4. Location/room where self injury took place
5. Wounds: How many? Where on body? Use of tool?
6. Thoughts & feelings after self injury
7. Reactions of others to the self injury
Enns, K. (2008). Self injury behaviour in youth: Issues and strategies. Winnipeg, MB: Crisis & Trauma
Resource Institute Inc.
Stopping Point
 When or how does client know to stop?
 Does client stop when they begin to feel pain?
 When does the client reach a stopping point?
 Visual aspect? Sensation of pain or numbing?
Wester, K. & Trepal, H. (2005). Working with clients who self injure: Providing alternatives. Journal
of College Counseling, 8, 180-189.
Alternatives to Self Injury
 Relaxation training
 Containment strategies
 Mindfulness, emotional regulation &
distress tolerance skills (DBT)
 Physical activity/yoga/sports
 Communication with others
 Negative replacement behaviors
Alternatives to Self Injury
Aggression/anger
Tear up newspaper or phone book. `
Throw ice cubes, rocks or eggs at
a wall. Punch a pillow.
Restlessness
Workout, go for a run, walk or bike
ride. Clean room. Make noise.
Emotional regulation Meditation, belly breathing, repetitive
counting, writing
Visuals
Draw red lines on arms. Draw slash
marks on paper. Paint areas on body.
Sensations
Snap rubber band on wrist. Ice cube
on skin. Clod shower.
Adapted from Wester, K. & Trepal, H. (2005). Working with clients who self injure: Providing
alternatives. Journal of College Counseling, 8, 180-189.
Cycle of Self Injury
Trigger
(Event or
situation)
Reaction
Anger, Shame
Action
Self Injury
Twisted Thinking
Automatic
Thoughts
Feelings
Fear, Anger, Sadness
-ve Self Talk
Cycle of Self Care
Trigger
(Event or
situation)
Reaction
Relief That Lasts
Action
Self Care
(Without Injury)
Am I Thinking
Straight?
Take a Breath
(Slow Down)
What am I Feeling?
(What Do I Need?)
+ve Self Talk
(I Can Handle This)
Slowing Down the Process
The key to recovery is to slow
down the process so the client
have time to consider what is
happening before they respond.
Trigger - Thought - Feeling - Self Talk - Action
Haswell, D., & Graham, M. (2008). 5th Edition. Overcoming self-abuse.
Hamilton, ON: S.A.F.E. in Canada.
Trigger -
Thought - Feeling - Self Talk - Action
What you do in response to an event
or situation is within your control &
depends on the following:
 What you think about what is happening?
 Your emotions are at the time
 What you believe about yourself, others & the world
 What you say to yourself about what is happening (Self Talk)
Haswell, D., & Graham, M. (2008). 5th Edition. Overcoming self-abuse.
Hamilton, ON: S.A.F.E. in Canada.
“Untwisting” Your Thoughts
Ask yourself am I thinking straight?
1. Am I jumping to conclusions? Without enough information?
2. Am I assuming the worst? Catastrophizing?
3. Am I over generalizing? Always, Everyone, No body?
4. Am I caught in “all or none” thinking? Extremes?
Haswell, D., & Graham, M. (2008). 5th Edition. Overcoming self-abuse.
Hamilton, ON: S.A.F.E. in Canada.
Changing Thought Patterns
1. Identify thought/belief about an event/situation
that is leading to unpleasant emotions
2. Evaluate the accuracy of thought/belief
 Am I taking an extreme view?
 How else can I think about this event/situation?
 Am I only looking at the negatives & ignoring the
positives?
3. Stop the thought by taking a deep breath &
replace the negative thought with a more helpful
thought
Enns, K. (2008). Self injury behaviour in youth: Issues and strategies. Winnipeg, MB: Crisis & Trauma
Resource Institute Inc.
Example
Start with an event: Traffic jam
Self Talk: I am going to be late. This is the
third time this week. My boss is going to fire
me! (Hot headed thoughts)
Take a breath. Are my thoughts helping?
What is another way I can think about this?
(Cool headed thoughts)
Alternative Self Talk: I don’t want this to be a
habit. Tomorrow I’ll give myself more time.
Managing Relapses
Changing thought patterns takes time and
practice. Relapses or return to self-injuring
patterns are often a part of the change process.
If a relapse occurs ask:
What do I need to do to get back on track a bit?
What has worked before?
What have I learned that will help in the future?
Self Care Without Self Injury
UNB Counselling services
Six-2 hr Group Sessions
Dr. Nancy Buzzell & Sarah Smith
Pre-Group Interview
Opportunity for prospective group members to:
 Meet facilitators
 See the group room
 Ask questions
 Be supported in determining their readiness
Pre-Group Interview
1. Does person have the ability to function on a day to day
basis? Ideally person should not be in personal crisis or in
the midst of a major life transition
2. Does person have the ability to discuss her self injury
issues without intense anxiety, dissociation or depressive
reactions? When it began, what occurred, extent of current
self injury
3. Does person have the ability to function in groups? Have
they been in other groups? Does she have any concerns
about being in a group?
Suggested Questions
1. Introductions
2. Can you tell us about yourself? Year? Program? Living
situation?
3. Can you tell us a bit about your self injury? How you are
currently doing regarding self injury?
4. Is there anything you are currently doing that helps a bit?
5. What are your reasons for participating in the group?
Suggested Questions
6. What do you want to get out of the group?
7. Can you tell us about the support you have for being in
the group? Family? Friends? Health care professionals?
8. Do you have any questions or concerns?
9. Do you think you would like to be in the group?
10. Can you commit to all six group sessions?
Group 1: Introduction & Safety
 Introductions
 Group guidelines
 Goals for the group
 Why self injury “works”
 Harm Reduction & Safety plan
 Belly breathing practice
 Check out
 Homework: Case studies
Group Guidelines
 Attendance
 Listening & all opinion accepted
 Confidentiality
 Self Responsibility & Option to pass
 Commitment
 Other: Scents, drinks/snacks
Group 2: Understanding Your
Behaviour
 Check In: Reaction to case studies
 History & function of self injury
 Addiction model & relapses
 Slowing down your cycle
 Progressive muscle relaxation
 Check out
 Homework: Increasing your odds
Group 3: Coping
 Check In & Increasing your odds
 Regulation of impulses
 Fear of losing control
 Anxiety relief technique (5,4,3,2,1)
 Surviving the urge
 Place in nature visualization
 Check out
 Homework: Coping Bank
Group 4: Managing Emotions
 Check In & coping bank
 Understanding your emotions
 Emotional expression without self injury
 Social context of anger
 Anger management strategies
 Check out
 Homework: Self help activities
Group 5: Facing Your Life
 Check In & self help activities
 Self esteem 101
 Self esteem & relationships
 Boundaries
 Leaf meditation
 Check out
 Homework: Boundary awareness
Group 6: Living in the Present
 Check In & boundary awareness
 Your relationship with your body
 Dear body letter
 Plans to continue self care in the future
 The rest of your life
 Raisin meditation
 Check Out
 Circle of gifts
Web Based Resources
www.lifesigns.org.uk
www.canadian-health-network.ca
www.selfinjury.com
www.safeincanada.org
www.siari.co.uk
www.youthnoise.com
www.selfinjury.org.uk/index.html
www.dailystrength.org
www.recoveryourlife.com
www.selfinjury.com/blog
References
.
Adrian, M. (2010) A cumulative risk model of non-suicidal self-injury: Contributions of emotion regulation
and contextual invalidation. Dissertation Abstracts International: Section B: The Sciences and
Engineering, 70, 44-72.
Alderman, T. (1997). The scarred soul: Understanding & ending self inflicted violence. Oakland, CA:
New Harbinger Publishers.
Gratz, K., & Chapman, A. (2009). Freedom from self harm. Oakland, CA: New Harbinger Publishers.
Haswell, D., & Graham, M. (2006). Overcoming self abuse.
http://ca.geocities.com/safebc/new_page_11.htm.
Heath, N. L., Ross, S., Toste, J. R., Charlebois, A. & Nedecheva, T. (2009). Retrospective analysis of social
factors and non suicidal self-injury among young adults. Canadian Journal of Behavioral Science, 41,
180-186.
Hoff, E. R. & Muehlenkamp, J. J. (2009). Nonsuicidal self-injury in college students: the role of
perfectionism and rumination. Suicide and Life Threatening Behaviour, 39, 576-587.
References
Hollander, M. (2008). Helping teens who cut. NY: Guilford Press.
Mahadevan, S., Hawton, K. & Casey, D. (2010). Deliberate self-harm in Oxford university students, 19932005: A descriptive and case-control study. Social Psychiatry and Psychiatric Epidemiology, 45, 211-219.
Ross, S., Heath, N. L. & Toste, J. (2009). Non-Suicidal self-injury and eating pathology in high school
students. American Journal of Orthopsychiatry, 79, 83–92.
Serras, A., Saules, K., Cranford, J. A. & Eisenberg, D. (2010). Self-injury, substance use and associated risk
factors in a multi-campus probability sample of students. Psychology of Addictive Behaviours, 24, 119-128.
Simeon, D., & Favazza, A. (2001). Self-Injurious behaviors: Phenomenology and assessment. In D. Simeon
& E. Hollander (Eds.), Self-injurious behaviors: Assessment and treatment (pp.1-28). Washington, DC:
American Psychological Association.
Wester, K. & Trepal, H. (2005). Working with clients who self injure: Providing alternatives. Journal of
College Counseling, 8, 180-189.
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