Working with Self-injurious
Youth in Schools
NYASP 2014
Steve Hoff, Licensed Psychologist
Associate Professor of School Psychology,
The College of Saint Rose, Albany NY
THE ALBANY-SCHENECTADY RAILROAD, THE
OLDEST IN THE UNITED STATES
The Mohawk and Hudson Company – in 1832
the first passenger train in America was run
over sixteen miles from Albany (intersection
of Madison and Western Aves) to Schenectady
According to the US patent office, Seth
Wheeler of Albany patented what was
called perforated wrapping paper ("toilet"
was a sensitive word in 1871). He patented
the idea to have the product wrapped
around a central tube in 1891, and is also
often credited with patenting a bracket to
hold those tubes.
 Google
hits for ‘self-harm’
◦ October 2014 – 3,020,000
Goth Culture
Google Images hit for “Emo”
Luv-Emo Website – Pics Boys
Luv-Emo Website – Pics Girls
Barbie
Italy Fashion Industry – Considering
Skinny Model Ban, 2006
Liposuction – Online Ad for
Plastic Surgery Practice

The direct, deliberate destruction or
alteration of one’s own body tissue without
conscious suicidal intent
Favazza, Bodies under siege (1987)

Self-mutilative behavior is deliberate, nonlife-threatening, self-effected bodily harm
or disfigurement of a socially unacceptable
nature
Walsh & Rosen, Self-mutilation: Theory, research
and treatment (1988)
Knife Inflicted Wounds
Eraser Burns
Plastic CD Cover “Carving”
Cigarette Burns


4% of general adult population
21% of clinical populations
12% - 38% of college and high school students
Whitlock & Knox, Archives of Pediatric Adolescent
Medicine (2007)

Prevalence by gender
◦ 11 year study of adolescents 12 – 18
487 males, 1633 females (70% female) – but more male
cutting likely
-at 12 years, M:F ratio was 1:8
-at 18 years, M:F ration was 1:2
Hawton, Journal of Child Psychology and Psychiatry
(2003)
“Unfortunately, many middle schools and high schools in
the US are experiencing an explosion of self-injury among
their students”
Walsh, Treating self-injury (2006)
Why Self-injury?
Perfect
Case Formulation
• How do I understand the presenting problem?
• What is the WHY behind the behavior(s)?
• What is the Intervention?
Normal Adolescent Development
Middle school Adolescents
What to expect:
• Puberty - It comes, but on a variable timetable. Some kids mature early,
some late. Boys – body hair, change of voice; Girls – menstruation, breast
development
• Body image - Cultural/media images and expectations
• Authority - Children start to pull away. Less idealized view of parents
• Peers - Increasingly important. Bullying and cliques can increase
• “Finding their Tribe” - Looking for belonging and meaning. “Where do I fit
in”? Social groups, rejection, popularity.
• Risk taking – Increases. Smoking, drugs, sexual experimentation
• Inconsistent judgment – Thinking and judgment are at times brilliant and
at times not
• Personality changes – Introspection, egocentrism, self-consciousness,
moodiness

Emotional distress. The self-injurer is
seeking relief – emotion regulation
◦
◦
◦
◦
◦
Depression
Alienation
Identity issues
Grief/loss
Abuse
“NSSI functions as a means both of regulating
one’s emotional/cognitive experiences and of
communicating with or influencing others”
Nock, Why do people hurt themselves? New insights into the
nature and functions of self-injury (2009)
Emotional State
Emotion
Before
During
After
76%
30%
14%
6%
45%
72%
Confused
63%
29%
28%
Clear-headed
11%
34%
47%
Depressed
88%
39%
36%
4%
22%
19%
Anxious
Calm
Elated
Internet survey of adolescent self-injurers. Murray, Warm and Fox
Australian e-Journal for the Advancement of Mental Health (2005)
n=128

Brain systems involved in self-injury
◦
◦
◦
◦

Limbic system: regulates mood/affect and pain
Dopaminergic systems
Serotonergic systems
Hypothalmus/pituitary/adrenal axis
Studies suggest many systems involved – not
a single pathway

Many different medications are used to treat:
◦ Antidepressants
 SSRIs (Prozac, Zoloft)


◦ Antipsychotics (Abilify, Zyprexa, Risperdal,
Clozaril)
◦ Mood stabilizers (Depakote, Tegretol, Lithium,
Topomax)
◦ Anxiolytics (Ativan, Valium)
No medication intervention is well established
Must consider long term vulnerability and
development, and current context
Harper in Walsh, Treating self-injury
(2006)


School must have a clear protocol for
managing self-injury
Must be informed by a systems-wide
approach
Self-injury
Suicide Risk
Assessment
Level of
Care
Intervention/
Services
“Even though most cases of DSH do not end in
overt suicide, DSH reflects that potential
underlying psychological pathophysiology, and
likelihood of eventual death from self-murder,
cannot always be predicted or prevented. It is
important to take all acts of DSH as serious, and
to offer comprehensive management to prevent
future acts of DSH and potential suicide”.
Greydanus and Apple, The relationship between
deliberate self-harm behavior, body dissatisfaction,
and suicide in adolescents (2011)

Differences in:
◦
◦
◦
◦
◦
◦
Depressive symptoms
Suicidal ideation
Social support
Self-esteem
Body satisfaction
Disordered eating
Brausch and Gutierrez, Differences in Nonsuicidal
self-injury and suicide attempts in adolescents
(2010)




Parents must be notified
Parents must be educated about self-injury
Parents must be part of a clear support plan
and must follow through on responsibilities
re: outpatient care
Family therapy may be indicated if family
issues are a key component

What is the level of risk?
◦ Question student about the frequency, duration,
intensity of self-injury
 Where does the self-injury occur – school, home,
other?
 Other dangerous behaviors? Drugs, risk taking, etc.
◦ Suicidal intent?
◦ What is the level of peer involvement and need for
follow-up?

Train staff to recognize and report
◦ What is self-injury?
◦ What should staff be on alert for?
◦ Pay attention in ‘hot spots’ in the school:
lunchroom, schoolyard, bathroom, gym
◦ Who should staff tell? School psychologist, guidance
counselor, social worker, nurse, administrator, etc.



Other self-destructive behavior (substance
abuse)
Depression/emotional negativity
Poor self-esteem
Miller & Brock - Identifying, Assessing, and Treating Self-Injury
at School (2011)


Risky sexual practices
Possession of things that could be used for
cutting
Lieberman et al. (2009) Non-suicidal self-injury in the schools:
Prevention and intervention. In Nixon & Heath Self-injury in
youth: The essential guide to assessment and intervention.




Scratches or burns that don’t appear
accidental
Frequently bandaged wrists and arms
Reluctance to change clothes or participate in
gym
Wearing long sleeves in hot weather
Reasons for self-injury contagion



Peer connectedness and identity
Competition to be ‘the real cutter’
Expression and communication of feelings
Response to manage contagion




Individualize and contain – divide and conquer
Engage self-injurers, individually, in meaningful ways, e.g.
sports, arts, being a helper, USE THE RELATIONSHIP
Build system-wide support plan: family, community, etc. for
each individual student
May have to implement disciplinary response – limit set

Individual

Groups
◦ Support work in school, intensive work with outpatient
clinician
◦
◦
◦
◦
◦
◦
Problem solving
Self-esteem building
Stress management
Social skills training/building peer relationships
CAREFUL with groups around cutting
Activities





Sports
The Arts: Music, Drama, Visual Arts, Dance
Adventure Based Counseling groups
Therapeutic animal contact
Family work – when appropriate
CLINICAL INTERVENTION






Think strengths (Brooks – “Islands of
Competence”)
Get the child to express her feelings
Acknowledge that she is hurting and that
cutting is her way of coping
Treat her with respect, express your belief
that she is capable and worthy of selfrespect, able to be responsible and in
control
Be willing to talk about specifics of cutting
& what’s behind it
Talk about alternatives to cutting





Think illness/pathology
Assume that she is cutting to get attention
Be shocked, angry, disgusted, disapproving
Minimize the importance that cutting holds
for her
Power Struggle




History of conflict in relationships
Difficulty having healthy connections
Few, if any, positive relationships with adults
Relationship with YOU can change her
perception of what relationships CAN BE
The Relationship
Six personality traits necessary to help a teen in crisis:
Confidence
Empathy
Knowledge
Understanding
Nurturing
Optimism
Steven Levenkron, Cutting, understanding and overcoming se
mutilation (1998)
Body Based Therapies
“The body keeps the score”
(van der Kolk,1996)


Rational Emotive Behavior Therapy
Albert Ellis
Dialectical Behavior Therapy
Marsha Linehan

Wisdom/Compassion/Mindfulness
Self-compassion
Wisdom and Compassion in Psychotherapy
Germer & Siegel (2012)





DIBs – Dispute Irrational Beliefs
Double Standard Dispute – “what if this were
your friend’s problem?”
Catastrophe Scale- “0 is resting at home, 100
is being shot”
Reframing – “not devastating, upsetting” or
“what are the positives of this situation?”
Blow-up Technique – combined with humor –
blow out of proportion to show irony, have
client laugh at their fear

MUST use homework in REBT
◦ Student practices what you came up with together
◦ Practice happens in the real world and the results
are brought back in to the work

Activity
DBT
Try to change AND try to Radically accept
• Mindfulness
• Interpersonal Effectiveness
• Emotion Regulation
• Distress Tolerance
Linehan – Treating BPD (1993)
Behavioral Tech
• http://behavioraltech.org/index.cfm
Breath
Interpersonal Effectiveness
Emotion Regulation
CAT EMOTION CHART
Distress Tolerance…
The Senses
Jen and the Cardinal
PROS AND CONS
Destructive behavior I wanted to do: __________________
Tolerating distress PROS
__________________
__________________
__________________
__________________
NOT tolerating distress PROS
__________________
__________________
__________________
__________________
Tolerating distress CONS
__________________
__________________
__________________
__________________
NOT tolerating distress CONS
__________________
__________________
__________________
__________________
Suicide Risk

Multiple contributing factors to consider:
◦ Conduct a thorough psychiatric exam, indentifying risk
factors and protective factors and distinguishing risk
factors that can be modified from those that cannot
◦ Can use scales. Beck Depression Inventory, etc.
◦ Ask directly about suicide/intent
◦ Determine level of risk: low, moderate, high
◦ Determine treatment setting and plan

Multiple attempters at much greater risk
M. David Rudd, Ph.D. Treating Suicidal Behavior
(2001)





Learned skills in problem solving, impulse control,
conflict resolution, and nonviolent handling of
disputes
Family and community support
Access to effective and appropriate mental health
care and support for help-seeking
Restricted access to highly lethal methods of
suicide
Cultural and religious beliefs that discourage
suicide and support self-preservation instincts
National Youth Violence Prevention Center (2004)

http://www.cssrs.columbia.edu/
Taking Care of the Caregiver:
This Means YOU!
• Seeing self-injury, and the results, can be shocking,
even sickening – it is okay to feel this way
• Manage our own stress
– Mindfulness, relaxation, alonetime, exercise, etc.