Understanding & Addressing Self-Harm. Jennifer Johnson, LCSW

Transcription

1 Understanding & Addressing Self-Harm Jennifer Johnson, LCSW

2 Self-Harm What It Is Common Myths & Current Facts Reasons Why People Self-Harm Psychological Treatment Choices Basic Strategies for Managing Self-Harm

3 All Behavior Is Goal Directed Self-Harm is typically about an attempt to cope and to get some kind of relief from intense emotional pain

4 Self- Harm Purposeful, deliberate, intentional act Act of inflicting physical damage to ones body (typically tissue damage in the form of lacerations, bruises, burns, or scrapes) Inflicting damage that is immediate in the moment (versus long-term damaging and reckless behavior like excessive drinking)

5 Self-Harm: The Intention is Not to Commit Suicide Most people who self-harm are trying to cope with their lives, not end them some people use self-harm to prevent killing themselves!

6 Most Common Types of Self-Harm Cutting Burning Biting Punching Hitting Scratching Picking at skin to the point of causing scrapes or cuts

7 Bottom Line If the behavior you struggle with is something you do on purpose to cause damage to your body, something that results in immediate physical damage, and something that s not an attempt to kill yourself, then it may be a form of self-harm.

8 Questions To Pose Do you do things to harm yourself, in the moment? Do the things you do cause visible tissue damage? Do you intend to harm yourself? Is that the reason you do these things? Are you doing this behavior without intending to kill yourself?

9 How Common is Self-Harm U.S. about 4% of adults have harmed themselves at least once in their lifetime 20% of high-school students (at least once) 40% of college students (at least once) 15 to 17% of college students (frequently)

10 We Need to Ask Different Questions

11 Reasons Why One Might Try Self-Harm Social Contagion People who are struggling with their emotions and unsure how to cope may be more likely to try self-harm if they see their friends, loved ones, or media figures engaging in self-harm Seeing people they know or respect harm themselves might make self-harm seem like a viable option

12 Reasons Why One Might Try Self-Harm Some people actually stumble upon self-harm accidently the first time Realizing that it distracted them from something they were upset about In that moment, all of their attention was focused on their physical pain instead of their emotional distress

13 Different Directions After Trying Self-Harm Some people try self-harm a few times, over the course of a year or two, and then grow out of it or decide that it isn't for them Similar to experimentation with drugs, alcohol, disordered eating Typically able to recover on their own or with support from a therapist or loved ones

14 Different Directions After Trying Self-Harm Some people SH occasionally over many years, just when things get particularly difficult They don t always harm themselves and may even go for years without But, when things get extremely stressful, they might go back to this behavior for a while and then try to stop again when the stress has passed

15 Different Directions After Trying Self-Harm Some people come to rely on SH in order to cope SH can continue over many years, even decades SH can take on a life of its own and get completely out of control

16 The More You Come To Rely On It The Harder It Can Be To Stop On Your Own The SH works so well and so quickly that some people find it harder and harder to resist using it even to cope with smaller problems that they might once have coped with in another way Coping Muscles Atrophy

17 Research shows us that Over time you begin to pay more attention to the positive consequences from selfharming such as experiencing a momentary sense of relief and escape! Devote less time to the negative consequences such as the scars, the hiding, increased lethality, creating worry in others, creating self doubt in yourself, lessening your belief that you can handle rough times, atrophy in your coping muscles.

18 Who Self-Harms In the past we thought it was only people who struggled with Borderline Personality Disorder that engaged in self harm

19 Out of all the people who self-harm approximately 25% are diagnosed BPD

20 Borderline Personality Disorder BPD a disorder characterized by instability in emotions, thinking, relationships, identity, and behavior A common struggle with managing ones emotions Tend to be more emotional than the average person often experiencing painful emotions that feel scary, uncontrollable, and threatening When upset they often have no idea how to make themselves feel better A common symptom is self-harm

21 75% of those diagnosed with BPD engage in self-harm

22 Caution Do not make the mistake that everyone who self harms is to be diagnosed with BPD That is Illogical and potentially harmful it would be like saying: Some animals with four legs are dogs, so I m going to assume that every animal with four legs is a dog

23 Not a Dog

24 It s Not About the Diagnosis If you self harm, it doesn't necessarily mean you have BPD or any other psychiatric disorder. Instead, it really only means that you re probably struggling with some difficult emotions and trying to cope with them in the way that seems to work best for you!

25 Who Self-Harms In the past it was thought that mostly females engaged in self-harm This came from the notion that males express anger and aggression outwardly (yelling/fighting) and that females tend to express anger and aggression inwardly

26 However The current research indicates that males and females have similar rates of self-harm Leading us to recognize that self-harm is not simply about expressing anger and aggression. There may have always been more females disclosing and accepting of treatment than males (gender socialization)

27 Who Self-Harms Self-harm is most common among adolescents and young adults (15-35) Similar age to all self-destructive and impulsive behaviors (excessive drinking, drug use, eating-disordered behaviors ) Less common in younger ages and older ages

28 Most Teens Do Not Self-Harm

29 Self-Harm In Childhood Sign that they are dealing with a lot of intense problems abuse, neglect, or other really stressful experiences Often means that the SH will last longer and be more severe than for people who start to SH later in life

30 Who Self-Harms More common in the LGB population Society in general doesn t completely accept people who don t identify as heterosexual Emotions experienced from this lack of acceptance include: alienated, alone, rejected, ashamed, less than It is exactly these kinds of experiences that can lead to self-harm

31 Most LGB Individuals Do Not Self-Harm

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33 Recipe For Possible Causes Your biology Your environment What self-harm does for you How you think about self-harm All these things work together to cause selfharm - no one cause operates completely alone!

34 Your Biology Biology the way your brain works, your brain chemistry and your genes Your biology might set you up to be vulnerable to developing self-harm Things that happen to you (such as trauma) might change your biology or brain activity, increasing your risk of self-harm

35 Keep In Mind Neuroplasticity research describes how neurons within the brain proliferate and grow new connections across the life span. Psychosocial genomics describes the process by which psychological and social experiences activate OR deactivate genes, thereby driving the development of new neural pathways. Psychotherapy produces changes in gene expression that in turn brings about changes in the structure of the brain

36 Chemicals In Your Brain The areas of the brain that seem to be involved in self-harm are the same areas that are directly related to pain and emotional distress Opioid System natural pain-relieving system Serotonin System emotional system

37 Low levels of Serotonin Related to depression, emotional distress, aggression People who SH have less serotonin activity in the brain s synapses than those who don t self-harm

38 Synapses in the brain are basically the spaces between two neurons Neurotransmitters travel from one neuron to the other, like ships traveling from dock to dock. It seems that people who SH basically have fewer ships leaving the dock; less serotonin traveling out of one neuron and over to another.

39 One of the major effects of a serotonin problem is irritability, and the lower people's serotonin activity, the more likely they are to act on this irritability by doing something impulsive or aggressive such as self-harm

40 Tie It All Together People who self-harm do so when they re upset People almost never say that they harm themselves when they feel happy or calm Intense negative emotions (which occur more for those with lower serotonin) seem to be very common triggers for self-harm Most people say they harm themselves in order to feel better emotionally

41 Opioid System Opioids are neurotransmitters that operate primarily in the areas of the brain related to pleasure, euphoria, and pain relief

42 Opioids are endorphins - your brains natural form of morphine. Released when you experience pain like a natural built-in pain killing drug!

43 Endorphin Rush

44 Possible Role Of Opioids in Self-Harm Some people who self-harm might actually experience a flood of opioid activity when they get hurt (including from self-harm), a stronger flood than in people who don t self-harm

45 Opioid Activity and Addiction Acts of self-harm trigger opioid activity Because opioid activity is related to pleasure, calmness, pain relief, and even mild euphoria, self-harm can serve as a way to obtain these these types of feelings

46 Self-Harm To Get A Rush Or A High If you have a very strong opioid response, you ll probably get a lot more pleasure or relief from self-harming than other people might get It s easier to get addicted to something that gives you a strong rush, euphoria, or strong emotional relief than it is to get addicted to something that only gives you a small amount of relief or pleasure

47 Elements of Addiction (93) Attempts to stop Preoccupation takes your time and attention away from living your life and dealing with your problems Tolerance - need more and more serious or frequent self-harm to get the same effect Withdrawal uncomfortable symptoms (97)

48 Preoccupation Tolerance Withdrawal

49 Personality and Self-Harm Personality is partly innate (born with) and partly shaped by our life experiences One personality trait that might make people more likely to self-harm, is impulsivity (tendency to act quickly without thinking about whether that action is actually a good idea: teach 5x) Some people who self-harm are more impulsive than people who don t self-harm

50 Remember Low Serotonin People who self-harm have lower levels of serotonin than people who don t self-harm So it makes sense for some, that self-harm and impulsivity go hand in hand

51 Low levels of serotonin are related to higher rates of impulsivity Serotonin Impulsivity

52 Impulsive People Hard time delaying gratification. Hard time waiting for relief when you feel bad, so you might turn to selfharm instead of using healthier coping strategies that take longer to work.

53 Personality Trait of Neuroticism Tendency to experience strong negative emotions. When people are VERY upset, they often do whatever they can to try to make themselves feel better in the moment!

54 Painful Childhood Experiences It was once thought that people who selfharm were abused as children We do know that many people who harm themselves have experienced physical, sexual, or emotional abuse - but not all It actually is that less than 1/2 the people who self-harm were abused in the past

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56 Distraction

57 Elements of Distraction The preparation and planning The sight of blood or tissue damage captures their attention The clean up & hiding

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59 Assess For Areas That are Putting You At Risk For Self-Harm Impulsivity Neuroticism or Negative Emotions Childhood Experiences

60 Impulsivity Do you have a hard time delaying gratification? Do you have a hard time stopping yourself from doing things that you know will get you in trouble? Do you seek out thrills or new activities? Do you feel the need for a lot of stimulation and activity? Do you often act on the spur of the moment without really thinking things through?

61 Neuroticism or Negative Emotions Do you often feel that you re in a negative mood? Are your negative moods really strong or intense? Do you often feel depressed or sad? Do you often feel irritated, angry or agitated? Do you feel stressed out a lot of the time? Do you sometimes feel so stressed and tense that you don t know what to do? Do you get stressed out about little things that others people don t get stressed about? Do you often feel worn down by all the stresses in life?

62 Childhood Experiences Were you mistreated or abused when you were a child? Was your relationship with your parents distant or detached? Do you feel as if you never got the emotional support you needed as a child? When you were growing up, did you often experience harsh punishment?

63 Negative Reinforcement Self-Harm Factors SH helps you get rid of something unpleasant: in the moment it releases tension, relieves emotional pain, distracts you from past memories or present negative thoughts or future worries Positive Reinforcement SH gets you something you want: feelings of euphoria, calmness or relaxed after selfharming and sometimes loved ones respond with warmth, support, attention, kindness (49)

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65 Effective Treatment

66 Underlying Issues An unfortunate myth is that you must resolve your underlying issues before you can stop self-harm OR That if you resolve your underlying issues your self-harm will go away

67 There is no evidence that hospitalization is better than less intensive treatments, such as meeting with a therapist on a regular basis Treatment Setting

68 The most common and well-known type of treatment is outpatient treatment Treatment Setting

69 Common Elements: Learning to Identify, Express and Experience Your Emotions as well as learning Self-Soothing Techniques

70 Treatments Dialectical Behavior Therapy (DBT) for BPD Emotion Regulation Group Therapy for BPD Manual-Assisted Cognitive Behavioral Therapy (MACT) for those that self-harm but are not BPD Acceptance and Commitment Therapy (ACT) which is an acceptance-based behavioral therapy

71 Dialectical Behavior Therapy (DBT) Emotional Regulation Skills Distress Tolerance Skills Mindfulness Skills Interpersonal Effectiveness Skills

72 Manual-Assisted Cognitive Behavioral Therapy (MACT) Is a CBT therapy and has DBT and PST elements For self-harm specifically (not BPD) Bibliotherapy 6 modules Life After Self-Harm Basic goal -to teach you problem-solving skills and other strategies for understanding what you re getting out of self-harm, managing your emotions and negative thoughts, preventing future episodes of self-harm, and learning healthier behaviors.

73 Problem-Solving Therapy (PST) Developing or enhancing a positive problem orientation and decreasing a negative orientation Training in rational problem solving (defining and formulating the problem, generating alternative solutions, making a decision, and solution verification) Reducing avoidance of problem solving as well impulsive and careless decision making

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75 General Interventions to Address Self-Harm

76 School Setting It is about Skill Development It is not a self-harm group Rather it is a: Healthy Life Skills Group Success in Managing Relationships Getting Through the Tough Times Learning About Me Health 101

77 Identifying Pros & Cons of Self-Harm Hard to remember the long-term Unfortunately, you are much more likely to remember the feeling of relief that usually comes right after you self-harm than you are to remember your feelings of shame, disappointment, or self-loathing that come later

78 Our minds actually make the strongest connections between events that happen close together in time. Event (Cut Relief) Sham e

79 Consequences of Self-Harm Positive Negative Short-term Consequences I felt relief, calm I was distracted, I escaped for the moment Messy, scary Long-term Consequences Maybe it still works I feel ashamed, weak, embarrassed I have to hide or lie or be fake, people leave or freak out, I m alone I could get really hurt or die

80 Identify Reasons Not to Self-Harm Come up with as many reasons as you can to not harm yourself Some may be similar to those indicated in the Pros & Con Table but many people will end up with more or with different ones (different style of learning table is more contrived) Make the list accessible It is too difficult to think (clearly & wisely) when you are really upset - so have the list accessible

81 Reasons Not To Harm Yourself You could scare your loved ones or make them worry You could harm yourself more seriously than you intended You might have to go to the emergency room You could accidently kill yourself Each time you harm yourself, it s harder to resist your urges the next time

82 Reasons Not To Harm Yourself You could get in trouble at school or work People may disapprove or think poorly of you Self-harm can take on a life of its own Self-harm makes you feel even worse about yourself in the long run Self-harm can actually make you more upset and cause more emotional pain Self-harm makes your coping muscles atrophy

83 Write All The Positive Consequences of Stopping Self-Harm The previous list had you focusing on all of the downsides of self-harm, this skill is all about focusing on the benefits of not self-harming Thinking of all the good things that will come along with stopping self-harm The P&C table, the list of reasons not to selfharm and this list of all the positives of stopping self harm - work to increase your motivation in different ways

84 Benefits of Stopping Self-Harm You won t have to worry about hiding your arms or other parts of your body where you harm yourself no more need for long sleeve shirts in the middle of July You may feel proud of yourself for resisting self-harm Your tolerance for your emotions will grow You will have more time and energy to spend on the things in your life that matter to you

85 Benefits of Stopping Self-Harm You may have more self-confidence when talking to other people No more new scars You won t end up in the ER because of your self-harm You can learn other ways of solving your problems and coping with your emotions

86 Get Rid of the Objects You Use To Harm Yourself Goal here is to make it harder to harm yourself impulsively, on the spur of the moment!

87 A Moment to Pause People often find that if they can just resist urges to selfharm for a little while, these urges will lessen so that they can focus on the reasons not to self-harm AND focus on the downsides that go along with selfharm AND they can give themselves enough time to use other skills!

88 Self-Harm Substitutes Substitutes don t help you learn to stop craving self-harm with substitutes you never quite teach your body and your brain to stop producing these urges It can be easy to take the substitutes too far and actually cause tissue damage You may begin to rely on the substitutes just as you did the self-harm

89 Need For Training For those of you working with people who engage in self-harm, you need to acquire training and supervision Self-Harm behavior is a difficult behavior, it can be addictive, it can be scary for all those involved, it can be lethal and it can be time consuming and the treatment of choice needs to be based on the recipe of the individual you are serving!

90 References Freedom From Self-harm by Kim L. Gratz and Alexander L. Chapman 2009 When Life Is To Painful: Finding Options After Self-Harm by Schmidt, U., and K. Davidson 2008 Contextual features and behavioral functions of self0mutilation among adolescence Journal of Abnormal Psychology 114(1): Nock, M. K., and M.J. Prinstein 2005

91 References Solving the Puzzle of Deliberate Self-Harm by Chapman A., K Gratz 2006 Behavior Research and Therapy 44(3): Self-mutilation and symptoms of depression, anxiety, and borderline personality disorder. Suicide and Life threatening Behavior 35 (5): by Andover, M.,C.M. Pepper, KA. Ryabchenko, E. G. Orrico, and B E. Gibb. 2005

92 References Kerr, P. L., Muehlenkamp, J. J., & Turner, J. M. (2010). Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. Journal of the American Board of Family Medicine 23(2), Selby, E. A., Kranzler, A., Fehling, K. B., & Panza, E. (2015). Nonsuicidal self-injury disorder: The path to diagnostic validity and final obstacles. Clinical Psychology Review, doi: /j.cpr