# Presentation: 356571

## Responding to Self-Injury

**Vic Carlson, Psy.D. ****Edison Job Corps**

**Doug Corey, M.A. ****Northlands Job Corps**

**Region 1 Wellness Conference**
**Boston: Sept. 27 & 28, 2006**

## Based on Treating Self-Injuryby Barent W. Walsh (2006)

**Worked with self-injuring persons since ****the late 1970’s.**
**Executive Director:*****The Bridge Central Massachusetts***** ****Network of 30 mental health programs**
**Conducted research, written extensively, and presented internationally on self-injury. **
**He has also consulted on the topic in many settings (schools, clinics, and hospitals).**

## Self-Injury is Not Suicidal

**Not about ending one’s life.**
**It is about reducing distress.**** **
**A strangely effective coping behavior (though a self-destructive one).**

## Rate of Successful Suicide

**Firearms****	****59.3****	****(2/3)**
**Suffocation****	****24.8****	****(1/4)**
**Poising****	****6.4**
**Fall****	****2.9**
**Other****	****2.5**
**Drowning****	****0.8**
**Fire / Burning****	****0.5**
**Transportation****	****0.5**
**Cutting****	****0.4 %****	**

## Terms to Avoid

**Not a “Suicidal Gesture”**
**Inaccurate and misleading**
**Can lead to empathic failure-****“You don’t get it!” **** **
**Not “Self-Mutilation”**
**Too extreme and sensational**
**Self-injury ******** mild to moderate damage**

## Intent & Methods

**Suicide**
**Escape pain**
**Unconsciousness**

**Frequent**
**Several methods**

**Self-Injury**
**Relief from pain**
**Too much or****Too little emotion**

**Rarely chronic**
**Few methods**

## Pre & Post Experience

**Suicide**
**Persistent**
**Unendurable pain**
**Hopeless/helpless**
**Only way out**

**Self-Injury**
**Intermittent**
**Uncomfortable**
**Some optimism**
**Choices & control**

**Feel worse **

**Rapid relief**

## Core Problem

**Suicide**
**Depression**
**Rage about****unendurable pain**** **

**Self-Injury**
**Overwhelming****emotions**
**Body alienation**
**Poor body image**

**New Group**
**Intense stress**
**Poor self-soothing**
**Peer endorsement**

## New Group

**May not have history of abuse**
**Often have major strengths**
**Large group of friends**
**Peers play an important role:**
**Also engaging in self-injury**
**Reinforcing with support**

## Initial Response

**Use the Client’s Language**
**e.g., “cutting, scratching, carving”**
**It’s joining, respectful, empowering.**
**Rule out Suicidal Intent**
**Avoid Inflammatory Terms**
**Not “suicidal”**
**Not “self-mutilating”**

## It’s Not Just for Attention

**A pejorative response, stigmatizing**
**Often in response to distress**
**Many other ways to get attention**
**But can be a secondary reinforcer**
**Those who inadvertently ****reinforce the behavior****need to be part of ****the response plan.**

## Problematic Responses

**Recoil,  Shock,  Avoidance**
**Too upsetting**
**Disorganizing for the caregiver**
**Stigmatizing for the student**
**Concern & Support**
**Inadvertently becomes reinforcing**
**The more intense the response, **** the greater the risk of reinforcement.**

## Compassion vs. Concern

**Concern & Support  ****(problematic)**
**Suggests affective intensity**
**A yearning to be of assistance**
**A desire to quickly protect & intervene**
**Compassion  ****(recommended)**
**Acceptance**
**A neutral stance**
**No expectations of immediate change**

## Nonjudgmental Compassion

**They’re used to harsh, pejorative judgments.**** **
**Nonjudgmental compassion is welcomed.**** **
**Indicates you are ready to hear the rest of their story.**** **
**Encourages full disclosure. **

## Self-Injury Log

**Baseline of Wounds & Episodes**
**Extent of Physical Damage**
**Body Area**
**Use of a Tool**
**Room or Place ****of Self-Injury**
**Social Context**

## Self-Injury Log

**Antecedents**
**Cognitive ****(automatic thoughts & core beliefs)**
**Affective ****(primary reason for self-injury)**
**Behavioral ****(triggers and precipitants) **
**Consequences or Aftermath**
**Specifics of Psychological Relief**
**Self-Care and Communication**
**Social Reinforcement**

## Self-Protection Contract

**Commitment to Reduce Frequency**
**Replacement Skills**
**Self-Soothing & Distracting**** **
**Reward**** (often self-reward)**
**No Punishment if not Achieved**
**Or they will withhold information.**
**Unable to stop without treatment.**
**Contract for tx (or empathic failure).**

## Consequences at Job Corps

**Open for Discussion:**
**Do we put everyone who engages in ****self-injury on a medical leave?**
**Would this drive the behavior underground?**
**They can’t change without treatment.**
**Must rule out risk to self and others.**
**They may need treatment elsewhere.**

## Using Replacement Skills

**Select the Right Skills**
**Practice Diligently**
**Start when student is calm & focused**
**Over-learning skills will help later**** **
***Replacement skills have worked for many others and they will work for you ******if you find the right skills and practice, practice, practice.***

## Replacement Skills

**Negative Replacement Behaviors**
**Mindful Breathing Skills**
**Visualization Techniques**
**Physical Exercise**
**Writing**
**Artistic Expression**
**Playing or Listening to Music**
**Communication with Others**

## 9. Diversion Techniques

**Need multiple techniques**
**Watch TV**
**Play video games**
**Read a book**
**Not a higher order skill**
**To use as they are learning new skills**
**They already do these things... **
**So they may not be so effective**

## Common Approaches

**Cognitive Behavioral Therapy**
**Dialectical Behavioral Therapy**
**Body Image Work**
**Exposure Treatment**
**Trauma Resolution**

## Dialectical Behavioral Therapy

**DBT- Developed by Marsha Linehan**
**Treating Borderline Personality Dx**
**Teaching skills to regulate emotions**
**Mindfulness**
**Distress Tolerance**
**Emotional Regulation**
**Interpersonal Effectiveness**

## Bringing DBT to Job Corps

**Very helpful with difficult consumers ****at a community mental health center.**
**Recently applied more broadly.**
**Most self-injury is an effort to cope with strong emotions.**
**At Job Corps, students...**
**Complain about “drama”**
**Are drawn to it**
**And are triggered by the drama.**

## Group of Young Women

**Had a history of self-harm.**
**Living in the same dorm / room.**
**Triggering and reinforcing each other.**
**Decided to meet with them as a group.**

## First Group

**Ground Rules ****(respect, confidentiality...)**
**Establish Safety and Support**
**Don’t want to make them feel bad.**
**Not judging them in any way.**
**They are doing the best they can.**
**Intro to DBT**
**Biosocial Model**
**Validating & Invalidating Environments**

## Validating Environment

**Imagine you’re a caregiver of a young child (2 or 3 years old).**
**Scared by a dog...**
**that you know **
**is not a threat.**
**Child runs to you...**
**What would you do?**

## What You Do:
Comfort them physically
Reflect their feelings
Reassure them verbally

What this Does:
Teaches them to identify feelings.
Feelings are uncomfortable, but it’s O.K. to express them.
Feelings will pass and you can go on.

**Comfort them physically**
**Reflect their feelings**
**Reassure them verbally**
**What this Does:**
**Teaches them to identify feelings.**
**Feelings are uncomfortable, but ****it’s O.K. to express them.**
**Feelings will pass and you can go on.**

**Validating Response**

## Invalidating Response

**How *****their *****caregivers responded:**
**Many examples of invalidation.**
**They had all been traumatized.**** **
**What this taught them:**
**Hide your feelings.**
**Bad things will happen ****if you express your emotions.**
**They keep building up until ****relief through self-harming behaviors.**

## What about their Group?

**Immediately understood they had been inadvertently ****triggering and reinforcing**** ****self-harming**** behavior.**
**What else could they do?**
**It’s how they were raised.**
**It’s all they know.**

## Self-Harm as Coping

**DBT Maxim**
**Solve the problem if you can.**
**If you can’t solve it, survive it.**
**Self-harm **
**An effort to survive a problem they couldn’t solve.**
**They were doing the best they could ****in their invalidating environment.**

## Other Coping Skills

** **
***Skills Training Manual for Treating Borderline Personality Disorder***
**Marsha Linehan (1993) **
**New York: Guilford Press**

## Distraction Skills

**Activities**
**Contributing to Others**
**Compare Your Fate to Others**
**Opposite Emotions**
**Pushing Away**
**Distracting Thoughts**
**Other Sensations**

## Walk On...

**Ground Hog Story**
**Anger isn’t bad, but...**
**If you keep concentrating on it, **
**things won’t get better and **
**they might get worse.**

## Homework

**Homework**

**Try some distraction skills.**
**Try validating each other.**

## Second Group

**Emotional Mind**
**Valuable and necessary.**
**Can’t always act from emotion.**
**Reasonable Mind**
**Logical, problem solving.**
**Sometimes eclipsed by emotion.**
**Wise Mind**

## Distress Tolerance

**Imagery**
**Meaning or Purpose**
**Prayer**
**Relaxation**
**Focus one thing; in the moment**
**Brief Vacation from your troubles**
**Encouragement**

## 3rd Group: Myths re. Emotions

**There’s a right way to feel in every situation.**
**Letting others know how I am feeling bad is weakness.**
**Negative feelings are bad and destructive.**
**Being emotional means being out of control.**
**Emotions can just happen for no reason.**
**Some emotions are really stupid.**
**All painful emotions are a result of a bad attitude.**
**If others don’t approve of my feelings, I obviously shouldn’t feel the way I do.**
**Other people are the best judge of how I am feeling.**
**Painful emotions aren’t important and should be ignored.**

## Recommendations

**Get Training in DBT**
**Purchase: *****Skills Training Manual for Treatment Borderline Personality Disorder*****  by Marsha Linehan.**
**Adapt the material for JC groups.**
**Develop staff trainings:**
**Responding to students.**
**Dealing with their own emotions.**

## Work Together / Support Each Other