Understanding and
Addressing SelfInjury in Schools
Sara Burd
Behavioral Health Coordinator
Reading Public Schools
sara.burd@reading.k12.ma.us
Self- Care for Today
Our topic is sensitive and at times participants may feel
uncomfortable or experience difficulty processing information.
Please take care of yourself and feel free to step out of the room,
take a break, grab a drink, etc. as needed to care for your needs.
Different Terms
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Self-harm
Self-injury
Self-mutilation
Repetitive Self-Mutilation Syndrome (RMS)
Para Suicidal behavior
Cutting
Self-abuse
Self-inflicted violence (SIV)
Self-injurious behavior
Definition
Self-injury is a volitional act to harm one’s body without intention
to die as a result of the behavior.
(Favazza, 1996, 1987; Simeon & Favazza, 2001)
The deliberate, impulsive mutilation of the body, or body part, not
with the intent to commit suicide, but as a way of managing
emotions that seem too painful for words to express.
While self-injury is generally not about suicide, the behavior comes at
the cost of:
• Bodily harm
• Potential scarring
• Social stigma
Methods of Suicidal Behaviors
• High lethality behaviors that frequently pose risk to life and
may result in death include:
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Use of gun
Suffocation ( hanging)
Poisoning (overdose, carbon monoxide)
Jumping from a height
Caution!
• While suicide and self-injury are separate and distinct
behaviors, they can occur in the same individual.
• Ongoing assessment should focus not only on self-injury but
also on suicidal thoughts, plans and behaviors.
Methods
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Cutting
• Constricting the flow of air
passages
Scratching
• Limiting the blood supply
Burning
to body parts
Preventing the skin from
• Cutting off body parts
healing
Bruising or breaking bones
Head banging
Biting
Hair pulling
Punching self or objects
Hitting the body with
objects
Self-Harm Behaviors
Direct
• Suicide attempts
• Major self-mutilation
• Stereotypic self-injury
• Moderate/superficial
self-injury
Indirect
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Substance abuse
Eating Disorders
Physical risk-taking
Situational risk-taking
Sexual risk-taking
Unauthorized
discontinuance or
misuse of psychotropic
medications
Incidence and Prevalence
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Varying statistics
1% of population
(National Mental Health Website)
4% in a community sample of adolescents
(Garrison, et al. 1993)
13.9% of adolescents in more recent school
samples
(Ross & Heath, 2002)
Incidence and Prevalence
• Age of onset is usually age 12-14
• More females than males, however, significantly present in
both genders.
• All races and socio-economic groups
Myth Busting
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Cutters are suicidal
Self-decoration is self-injury
All have been physically or sexually abused
Self-injuring adolescents have borderline personality disorder
These kids need to be hospitalized
(see myth vs fact handout)
Possible Motivators
Self-injury is seen as a maladaptive coping mechanism
• To reduce intense feelings such as anxiety, depression, anger,
sadness, tension, contempt, guilt and shame
• To relieve too little emotion or states of
dissociation/numbness
Why People Self-Injure
To communicate something:
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For acknowledgement (please acknowledge I am upset)
To punish (look what you’ve done to me)
To change behavior of others
To produce withdrawal (now you’ll give me space)
To coerce ( if you break up with me, I’ll hurt myself)
To elicit a response from caregivers, family members or significant others:
• Competition for scarce resources (squeaky wheel)
• Anticipation of aversive consequences (If I hit you I get
suspended, if I cut myself I don’t)
Students Report They Harm to:
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relieve tension
feel alive inside
gain control
numb themselves
vent anger
re-associate
relieve emotional
distress or overwhelming
feelings
• gain euphoria
• stop bad thoughts
• purge out bad feelings
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hurt and/or control others
feel the warm blood
see “red”
to release emotional pain
because their friends all do it
scars show battles won
self punishment
for ritualistic nature
to replace emotional pain with
physical pain
• immediate release for anger
Experiences that May Trigger SelfInjury
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Recent loss
Peer or family conflict
Intimacy problems
Body alienation or dissociation related to abuse
Impulse control problems
Drug or alcohol use
Trauma
Risk Factors
• Having friends who self-injure and communicate about the
behavior extensively
• Being prone to intense emotional distress with limited abilities to
manage it
• Episodic anxiety, depression
• Spending time on websites, message boards or chat rooms
dedicated to self-injury
• Being pre-occupied with music, stories, art, about self-injury
• Performance problems or stresses in areas of school, work, athletics
or extracurricular activities
Physical Signs
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Inappropriate clothing for the weather
Blood stains on clothing
Unexplained scars, bruises, or cuts
Possession of sharp implements (razor blades, thumb tacks,
knives, etc.)
• Secretive behavior - spending unusual amounts of time in
bathroom, other isolated areas
Emotional Signs
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Unable to cope with strong emotions
Excessive anxiety and fears
Excessive rage, depression
Poor self-esteem or self-loathing
Not connected with positive support system
Increased isolation and withdrawal
Art and writing displaying themes of pain, sadness, physical
harm
• Changes in social interactions or interests
Can Be Ritualistic in Nature
• Certain times
• Certain rooms
• Certain objects
Co-morbid Disorders
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Anxiety
Depression
Bi-Polar
PTSD
Eating Disorders
Substance Abuse
Borderline Personality
Protective Factors
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Healthy emotion regulation skills
Ability to self-soothe
A strong support network
A positive body image
Positive thoughts and beliefs
Cognitive Behavioral Therapy
Examples of distortions in thinking:
1. Self-injury is acceptable
2. One’s body and self is disgusting, and deserving of selfpunishment
3. Overt action is needed to tolerate unpleasant feelings and
communicate feelings to others
4. Self-injury doesn’t hurt anyone
5. It’s the only way to know people care
6. It keeps people away
7. If I don’t have it, I will kill myself. It’s the only thing that works.
8. I can’t control it.
Other Types of Therapy
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Family therapy
Addiction treatment
Trauma/abuse treatment
Medication
Dialectical Behavioral Therapy
Combination of above
Group therapy not recommended usually
Therapist Recommendations
• Many therapists not well-trained in areas of self- inflicted
violence
• Much secrecy surrounding the behavior
• Goals of therapy should be related to underlying cause of pain
Examples of Positive Coping
Strategies
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Communication strategies
Exercise programs
Relaxation, stress management
Mindful Breathing (Kabat-Zinn, 1990)
Meditation, Visualization
Art therapy
Journaling
TALK TO SOMEONE!!!
Students should be in school during treatment - respond well
to structure, normalcy, safety
S.A.F.E (Self-Abuse Finally Ends)
1-800-DON’T CUT
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Inpatient and out patient services for serious self-injury
When self-injury is interfering with ability to function
Person must self refer
Insurance is accepted
Mobile Crisis Unit
• Eliot Community Human Services
• 24/7 Prompt team response to behavioral health crisis
• 1-800-988-1111
• www.eliotchs.org
• Donna Kausek, Program Director
School Best Practices
What School Mental Health Can Do
• Provide awareness and knowledge
• Educate students to report self and others
• Educate school staff
• Use a team approach, when necessary
• Assess for safety, co-morbid disorders and suicide
• Develop safety plan
• Notify and collaborate with parents
• Collaborate with community support
• Control the contagion effect
Awareness and Knowledge
It is our professional & ethical obligation to:
• Practice within the boundaries of our competence
• Be able to identify students who self-injure
• Differentiate self-injury from suicide attempts
• Know that it is not “just attention getting” behavior
• Understand the contagion effect
• Know our community resources to make appropriate referrals
• Understand our legal & ethical obligation to report
Educate Students to Report
• Report all dangerous behaviors to an adult who can help.
• Do not use awareness campaigns about this topic or describe
behaviors to students.
SOS: Signs of Suicide
ACT- Acknowledge Care Tell
Educate School Staff
• Educate them about the warning signs
• Understand self-injury as coping attempt not suicide attempt
• Train staff to identify and appropriately respond to these
students
• Staff should not just tell the student to “stop”
• Report behavior to school mental health personnel
Responding to the Student
Do
• Approach the student in a calm and caring way
• Accept him/her even though you do not accept the behavior
• Let the student know that you care about them and believe in
their potential
• Understand that self-injury may be their way of coping with
emotional distress
• Understand that self-injury is usually not about suicide
• Refer the student to the counselor, social worker, nurse
• Offer to go with the student to see the professional helper
• Remember that the teachers role is not to solve the problem
but to refer the student to a trained professional
Responding to the Student
Don’t
• Say or do anything to cause the student to feel guilt or shame
• Act shocked or appalled by their behavior
• Talk about their self-injury in front of the class or around peers
• Lecture them as to what you think they should do
• Judge them or conclude they are doing it just for attention
• Promise the student to keep the self-injury confidential under
any circumstances
• Use punishment or negative consequences if a student selfinjures
• Make deals in an effort to get the student to stop self-injuring
Assess for Co-morbidity and
Suicide
• Check for signs of other co-morbid disorders such as
depression or drug use.
• Assess for suicidal ideation
• Be direct with questioning about topics involving danger to
self or others
Develop a Safety Plan
• Short term plan serves to help stabilize student until
community support can begin
• Do not emphasize expectation that student is not to selfinjure; to stop behavior
• Help students to identify the triggers for the behavior and
possible physical cues
• Help to understand the function of the behavior
• Encourage student to talk to someone before cutting - give
help line phone numbers
• Remove objects, etc. when possible
No Harm Contracts
• What is a no-harm contract?
• Not recommended as a strategy for working with these students in
schools without other intervention
Reporting Self-Injurious
Behavior
Three situations in which the school mental health provider is
obligated to share confidential student/client information:
1. When student requests it.
2. Situation involving danger to the student or others (duty to
protect).
3. When there is a legal obligation to testify in a court of law.
Ethical Considerations
NASW, NASP and APA
• Do no harm
• Provide services within competency and enlist assistance of
others
• Inform of limits to confidentiality
• Promote parental participation in designing services provided
to children
• Referral for service
Other Considerations for Limits to
Confidentiality
• Important differences from therapist-client relationship
• Permission needed for psychological treatment in schools
• School district policy
Parent Notification
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Notify and involve parents
Ascertain whether parents already know of behavior
What is already in place to support student?
Gather additional history
Document your parent contact
Collaborate with Community
Support
• Get a release to communicate with student’s therapist
• Understand the treatment goals and techniques in order to
reinforce in the school environment
• Our observations and feedback can often be helpful to
therapists
Controlling the Contagion
Effect
Assess factors that may be contributing:
• Direct modeling influence
• Disinhibition
• Competition
• Peer hierarchies
• Desire for group cohesiveness
• Pseudo-contagion episodes
(Walsh, 2005)
Controlling the Contagion
Effect
Strategies for managing and preventing contagion:
• Identify the primary status peer models
• Communicate with them that they are hurting their peers by
communicating about self-injury
• Encourage them to communicate with school supports, family,
or therapist
• Ask them not to appear in school with visible wounds or scars
• In rare cases, students may have to be dealt with in a
discipline manner
(Walsh, 2005)
Personal Reactions to SelfInjury
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Violent nature of self-injury can be unnerving.
Watch for anger, disgust or sadness responses.
Growth and change can be slow.
Requires a large emotional investment. Watch for
helplessness, guilt or betrayal responses.
• Over-empathy or over-reaction.
• Watch for “attention-seeking”response
Practice
Find a partner…
You are a teacher of Karen’s. On Monday morning Karen pulls
you aside with tears in her eyes and tells you she had a very bad
night. Karen lifts her sleeves up and reveals bandages covering
cuts that were made recently. Karen tells you that she is going
to need some time to recover and asks that you be lenient and
not call on her in class today. Karen turns to walk away.
• You are a teacher of Ron’s. Ron is a leader in his classes and a
great student. On Wednesday you notice that Ron hasn’t
taken off his coat for hours despite the fact that the heat is
pumping hard and everyone is sweltering. His coat is wide
open and it appears he has short sleeve on underneath. You
begin to observe more closely and notice that Ron is
constantly pulling his sleeves down to cover his hands.
• You are Jamie’s counselor. Jamie has just shared with you that
she self-injures by burning large portions of her skin with her
hair straightener. Jamie does not feel she is able to stop or
slow her behavior right now and is particularly stressed and
triggered by her recent breakup. Jamie does not want you to
tell anyone.
• You are Karen’s counselor. Remember Karen? Karen was
referred to you by her classroom teacher and has shared with
you the details of her self-injurious behavior. You are about to
call her parents. Karen is worried her parents will overreact or
punish her.
Mindfulness
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Outside- In
Leaves on a river
Raisin reflection
The Guest House Poem
Yoga 4 Classrooms
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Balloon Breath
Ocean Breath
Bumblebee Breath
Power Breath
Rock the Baby
Monkey Arms
Chair Pose
Eagle Pose
King Dancer
Tree
Half Sun Salute
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Warrior
Loosen the knots
Magic Massage
Washing Machine
Positive Opposites
Change the Channel
Resources
SELF-INJURY:Awareness and Strategies for School Mental Health
Providers
Linda Kanan, PhD, Jennifer Finger, MSW, LCSW
New Developments in Understadning and Treating Self-Injury
Barent Walsh, Executive Director: The Bridge of Central
Massachusetts, Inc
SOS: Signs of Suicide Middle and High School Suicide Prevention
Program
Yoga 4 Classrooms: Tools for Learning, Lessons for Life. Lisa Flynn