A student reveals that s/he has engaged in self

Welfare Guardian
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Welfare Guardian
Responding to Self-harm in
Dr Erin Bowe
Clinical Psychologist
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
Introduction: Goals of session
 To better equip yourself and staff to deal with common
 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 nonemotive language
 To have a clearer understanding of how to seek further
advice and support for yourself, staff, students and parents
Understanding self-harm behaviours
Responding to crisis
Communication skills
Special considerations within school settings
Self-care, supervision and referral
Pre and post-workshop
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
 Understanding best-practice treatment approaches for self-harm?
 That you could handle a crisis?
Self-harm is
 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 in this context is not
to be confused with:
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)
Stressful events
specific factors
Regulation of emotional
Cognitive-emotionalbiological vulnerability
•High emotion reactivity
•Emotional numbing
•Poor distress tolerance
•Thought suppression
•Stressful event
Triggers over or under
Arousal (automatic
Functions) OR
•Event presents high
Social demands
Social vulnerability
•High selfcriticism
•Modelling of
•Need for
(Social function)
•Early abuse/maltreatment
•Familial hostility/criticism
•Poor communication skills
•Poor problem solving
Regulation of social
Psychological model of the development and maintenance of self-harm (Nock & Cha, 2009)
Who does it?
 Appears to be 3 possible pathways
‘One-off’, non-rewarding response (about 30%)
Tension reduction* response (about 70% will repeat)
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
‘Typical’ response: tension
reduction model
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
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
Faulty Assumptions- “why?”
 Most people have a hard time explaining “why” they cut
 But can describe what, where, how led to the behaviour
 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
Crisis #1
 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 continued
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 #2
 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 continued
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.
Non-immediate crisis
 A student reveals that s/he has engaged in selfharm (but no current crisis)
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 cont.
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)
Send students home?
 No, not unless absolutely necessary
 Tends to reinforce the behaviour
 Increases feelings of rejection & isolation
Self-harm in groups & cliques
 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
Addressing the Issue: Groups?
 Can be effective if student has a circle of non selfharming 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
Risks with 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
Communication skills
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
 Focus on the factual information about the mechanics or the process
(i.e., reduces heart rate, body releases natural feel-good opioid
Realistic options for school
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
Road blocks to student care
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
Referring out
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)
Worksheets and Handouts
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
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
 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
Post-workshop reflection
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
 Understanding best-practice treatment approaches for self-harm?
 That you could handle a crisis?
 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
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