School Health Conference
July 18-19, 2007
Elizabeth Rose, MEd
Counselor, Searcy High School

Self-injury (SI) has been defined as “all behaviors involving the deliberate infliction of direct physical harm to one’s own body without the intent to die as a consequence of the behavior” (Simeon &
Favazza, 2001)
Physically harming one’s own body in order to feel better.

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This group of disorders includes alcohol and substance abuse, suicide attempts, shoplifting, and eating disorders.
Impulse behaviors have two factors in common:
1) They occur episodically
2) Some gratification achieved by the behavior

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A failed suicide attempt
A disease
An addiction (although it’s addiction-like)
An attention getting behavior
A manipulation tool
An indication that the self-injurer is dangerous to others
A tattoo or piercing
A phase

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The key to determining if it is SI is the intent- What is the intent of the person?
It’s not self-injury is the primary purpose is:
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Sexual Gratification
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Body decoration (body piercing, tattooing)
Spiritual enlightenment via ritual
Fitting in or being cool

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80% of individuals who are suicidal report suicidal ideation and give advance warning of their suicidal intentions
Rarely does the person who self-injures report suicide ideation or give any advance verbal warning of the SI behaviors
The intention behind SI is not to stop living- it’s a coping strategy to deal with intolerable pain-a way of surviving. However, there is always the risk that once the method stops working, they could commit suicide-either accidentally or purposefully.

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Among clinical populations, SI is comorbid with borderline personality, eating disorders, PTSD, depression, anxiety disorders and a history of abuse or trauma
Some researchers calling for a new DSM impulse-control disorder- deliberate self- harm syndrome
Most see SI as a manifestation of mental or emotional disorders or of childhood trauma

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Documented since biblical times-Mark 5:5 describes a man who “night and day would cry aloud among the tombs and on the hillsides and cut himself with stones.”
First case of client who engaged in SI was published in 1846
S.A.F.E. (Self-Abuse Finally Ends) Alternatives founded in 1984 as the first outpatient support group by Karen Conterio; first structured inpatient program in 1985
Dr. Armando Favazza wrote the first comprehensive book about SI, Bodies Under Siege, in 1987

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Major Self-Mutilation
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Stereotypic Self-Mutilation
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Moderate or Superficial Self-Mutilation

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SI is not a recent occurrence, but behaviors have become more widely publicized and discussed
True prevalence remains unclear-no reliable estimates of the prevalence of SI among the general US adolescent population
Best estimates indicate 1%-4% of general population self-injures
Several studies indicate around 13% of adolescents engage in self-injury (4%-38% range)

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Cutting (72%)
Burning/abrasions (15%-35%)
Self-hitting (21%-44%)
Skin-picking (22%)
Hair-pulling (10%)
Interfering with wound healing

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Cutting and Burning are the most common types of SI
Some scratch or “draw” delicate web-like lines
Common weapons include razor blades, knives, scissors, needles, safety pins, paper clips, eraser holders, thumb tacks, aluminum or glass
Some use sharpened pencils, pen caps, “Coke can” tabs, bottle caps or credit cards- injurers become very resourceful and can turn anything into a weapon
Cutting ranges in intensity from superficial nicks to deep gouges

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Some make rounded punctures in their skin using sharply rounded objects
Arms and legs are most common targets, followed by breasts, abdomen, thighs and genitals
Sometimes they carve words into their skin- “fat” and “ugly” most common for teenage girls
Many progress from cutting to burning finding they need to wound themselves more severely to get the same relief or “high”
Some vary their cutting tools and some rely on a single tool

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When the body is injured, it releases natural opiates that help dull pain
The brain secretes endorphins that are natural antidepressants.
Cutting inflicts a very real injury, and selfinjurers may be seeking the neurochemical kick that follows.

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Twice as many females as males
Specific ethnicity prevalence rates inconclusive
14 (or freshman year of high school) is the common age for first engaging in SI
Typically have low self-esteem and self-worth
Have a perception that they are “not as good as” their peers and are unable to live up to the expectations placed upon them

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Up to half of self-injurers have suffered sexual abuse
Many self-injurers also have or have had an eating disorder (one study found 61%)
May have suffered from physical or emotional neglect or abandonment by a parent or caregiver
Significantly more likely to meet the diagnostic criteria for depression than those who do not self-injure

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May have suffered the loss of a parent through divorce or death
Tense or abusive relationship between the parents may exist
Lack of communication concerning emotional issues part of the family dynamics
Common Denominator: Grown up in
“invalidating environments”

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Helpless
Alone
Secretive/Ashamed
Desperate/Lonely
Impulsive
Proud of being “tough”
Label self “bad”
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Out of touch with physical body
Invisible
All or nothing thinking
Blames self for events out of their control
No ability to selfsoothe

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Overwhelmingly, self-injurers say they began cutting for one of two reasons: to escape their feelings or to feel something, anything
(to feel less or to feel more)
To cope with feelings of confusion and emptiness
To ease tension/release emotions
To express emotional pain they feel they cannot bear

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To make themselves unattractive or punish bodies they believe betrayed them
To validate their emotional pain- the wounds serve as evidence that those feelings are real
To escape emotional numbness
They can not think of any other way to deal with the pressures that they are experiencing
They perceive a situation as unsolvable
Whatever the reason, it is always about coping

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Recent Loss or Death
Peer Conflict
Intimacy Problems
Impulse Disorder
A Rejection of Human Interconnection
Memories of Trauma*
Sights*
Smells*

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Mood swings
Low self-esteem
Poor impulse control
Sadness/tearfulness
Anger
Anxiety
Disappointment in themselves
Inability to identify positive aspects of their lives
Artist: sarah lynn Title: self portrait http://galleryofpain.self-injury.net

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Fresh or healing wounds or scars- most prevalent on the arm opposite the student’s dominate hand and more likely on the forearm at an angle
Parallel scars or cuts, or scars or cuts on only one side
Blood or burn stains on inside of clothing
Locking him/herself in the bathroom for long periods of time
Finding sharp objects hidden in their bedroom or the bathroom

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Wearing long sleeves or pants even on hot days
Sudden shifts in mood- “If a teen is mopey at
5:00 and much better at 5:30 you may want to know what happened in that half-hour”
Not wanting to participate in activities where you must change clothes at school or around other people
Becoming very defensive when questioned about wounds or scars

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Provide Intervention
Notify Parents or
Appropriate
Personnel
Assist/Refer
Advocacy
Educate
Prevention
Artist: julieli Title: sorry http://galleryofpain.selfinjury.net

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Be aware of risk factors
Open communication with faculty and staff
Elicit information from students with non-threatening questions: “What is this from?”, “Could you say more about this?”
Create a safe environment
Foster a strong alliance with the student

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Issue of confidentiality
Parent’s rights vs. ethical responsibility to child client- “Ethically the child is the client but legally the parent is the client” (Ritchie & Norris Huss,
2000)
Encourage student to share important information with parents
Familiarize yourself with state laws and codes
Legally, school counselors are obligated to contact the student’s parents or local authorities in helping the student

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Become familiar with community agencies and private practitioners before the information becomes needed
Assist the adolescent and his/her family in finding a mental health provider who treats adolescents who SI
Collaborate with the community professional and continue to play a role in the student’s treatment process (safe person)

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Advocate for students through faculty inservices and parenting groups, and speaking in health classes to students regarding self-injury
Help dispel myths and break down stereotypes regarding self-injury
Encourage staff to release students from class to visit the counselor when negative emotions surface

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Educate teachers and other staff regarding self-injury, how to recognize the signs and how to respond appropriately
Educate teachers and other staff on the importance of listening and empathizing with students
Incorporate SI training into your crisis team responsibilities
Educate parents

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Talk to students about what to do if they suspect a friend self-injures
Provide students with resources about what to do and whom to talk to about getting help for friends
Use caution when educating studentsavoid descriptions of why and how students hurt themselves

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Always be supportive and show unconditional acceptance
Communicate that it is okay to talk about self-injury
Help them to understand that there is an underlying cause for the behavior
Suggest a list of coping techniques to be used rather than self-injuring

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Schools are not responsible for treating the adolescent.
It is our job to be aware that the behavior exists, detect the behavior, and react appropriately so as not to further isolate the student.

Artist: julieli Title: Two Sides to
Every Story http://galleryofpain.selfinjury.net
Self-Injury is the injurer’s attempt at a solution to a problem, but is not the problem itself.
Therefore, to stop the injury, the underlying problems- the
‘why’- must be addressed.