Understanding Self-Mutilation 1

Transcription

1 Understanding Self-Mutilation 1 Running head: UNDERSTANDING SELF-MUTILATION Understanding Self-Mutilation in Adolescents: A Practical Assessment and Screening Model Lavona Bailer Supervisor: Dr. Jacqueline Pei CAAP Final Project: Letter of Intent November 26, 2006

2 Understanding Self-Mutilation 2 Understanding Self-Mutilation in Adolescents: A Practical Assessment and Screening Model Problem Statement Self-mutilation, also known as cutting, carving, self-harm, and self-injury, is a perplexing phenomenon due to the number of factors that may contribute to self-mutilating behavior (SMB), along with the mixture of reactions it causes, ranging from shock, horror, revulsion, helplessness, sadness, and bewilderment. A definition provided by Nock and Prinstein (2005) states that selfmutilative behavior (SMB) refers to the direct and deliberate destruction of one s own body tissue without suicidal intent (p. 140). This destruction is often observed as repeated superficial cutting with a sharp object, such as a razor blade, scissors, pins, knives, pens, and fingernails. It may also include such behaviors as picking and pulling the skin and hair, burning the skin, inserting objects under the skin, self-punching, and scratching. The most common sites of SMB are the arms, wrists, ankles, and lower legs, with the resulting physical scars usually of a superficial nature. It is important to enhance understanding of this phenomenon, not only so there will be an awareness of the number of tools available to aid the practitioner in assessment and diagnosis of SMB, but to also assist in providing successful treatment models. Thus, the focus of this Campus Alberta Applied Psychology (CAAP) project is on the development of a practical assessment and screening model to assist the practitioner who encounters this behavior. This project will be based upon an extensive review of current literature regarding the phenomenon of SMB, the factors that lead to it, and its association with other disorders. The treatment models of SMB will be explored and potential areas for further research will be highlighted. The proposed theoretical assessment and screening model is intended as a preliminary tool to facilitate intervention and effective treatment.

3 Understanding Self-Mutilation 3 Project Rationale The growing prevalence of self-mutilation within the general adolescent population underscores the necessity of increasing an understanding of this behavior. In 1998, Favazza estimated the incident rate of SMB in the adolescent population to be between 1.5% and 2%. However, there is evidence of rates as high as 14%-39% in adolescent community samples (Lloyd, Kelley, & Hope, 1997; Lloyd, 1998; Ross & Heath, 2002). Lloyd (1998) sampled 143 high school students and found that 39% had participated in some form of self-mutilation within a year s time. Dibrino (1998) stated that non-lethal self-mutilation is becoming a common adolescent problem. The greatest increase of self-cutting behavior is currently found among adolescents who have no history of other disorders, such as schizophrenia or severe depression (Dallam, 1997; Favazza, 1998; Machoian, 2001). In addition, over the past 10 to 15 years, the issue has become increasingly addressed by the mainstream media, such as television programs, teen magazines, and websites, causing its profile to be raised even further. The alarmingly high rate at which adolescent self-mutilation occurs, coupled with the psychopathology and dysfunction often associated with such behaviors (e.g., Nock & Kazdin, 2002), underscores the need for a better understanding of how to effectively assess and treat these behaviors. According to Derouin and Bravender (2004), the true incidence of SMB is unknown because of its diversity and hidden nature and the limited or sensationalized information available about self-mutilation in the mainstream media, which frequently hinders its proper treatment. The practitioner who is aware of the phenomenon of SMB, along with the factors that lead to this, may discover, assess, and diagnose SMB earlier, along with the development of an effective treatment and intervention plan.

4 Understanding Self-Mutilation 4 Supporting Literature Why teens self-mutilate. One function of SMB is that it serves as a mechanism to provide relief from stress or anxiety. According to Dallam (1997), the self-cutting and subsequent bleeding provide intense feelings of relief for the cutter, and is followed by relaxation and repersonalization after bleeding. The bleeding serves as a reminder that he or she is alive, a result of dissociation from emotional pain. In addition, SMB becomes a distraction that reduces stress by refocusing attention from mental to physical pain. Many teens lack the cognitive and emotional skills needed to identify and cope with stressors, and resort to inappropriate mechanisms to manage their stress (Bravender, 2002; Walsh, 2002). Thus, it may be identified as a coping mechanism through which teens ameliorate the effects of stress and anxiety. Another function of SMB is that it can be used to express emotions. Machoian (2001) referred to it as a call for help used by teens to cope with psychological pain, especially when they believe that they are not being heard or understood. SMB becomes a way to express emotions that have become overwhelming and to alleviate emotional pain by focusing on a physical problem. It is a method that enables the adolescent to gain a sense of control and empowerment over complex emotional issues. Risk factors. A complex interaction of biological, psychological, and environmental factors appears to lead to SMB. Some significant predisposing factors are histories of sexual abuse, sexual identity issues, negative affect states, and disturbed childhood attachments. Research indicates that those who have been repeatedly abused are the most likely to inflict selfinjury (Kehrberg, 1997; Zila & Kiselica, 2001). Cutting then becomes a reenactment of childhood trauma and the pain felt during abuse, a method of communicating the unspoken, and a way to manage the psyche (Levenkron, 1998). It also involves a need to regain control by

5 Understanding Self-Mutilation 5 injuring the body. Self-mutilation may also be linked to an inability to handle emerging sexuality. According to Nock and Prinstein (2004), two functions of SMB include a reduction in tension or other negative affective state and the creation of a desirable physiological state (to feel something). The absence of parental nurturing in the form of loss of a parent through death or divorce, neglect, unhappiness, abuse, absence of appropriate attachment, and family disruption during childhood may cause individuals to be unable to maintain meaningful interpersonal relationships during adulthood. Emotional distance and isolation is achieved through the shame and secrecy that accompany SMB, since self-mutilators typically do not discuss their behaviors with others. The sensation of dissociation with oneself can extend itself to a lack of attachment to others, since self-mutilators may refrain from having any sexual or physical contact with others. Arnold and Babiker (1998) state that the act of self-mutilation seems to be associated with difficult and distressing life experiences, often beginning in childhood, with the typical onset of SMB being in adolescence and continuing for many years. However, the basic aspects of SMB, including the frequency of different methods and the average age of onset, have not been well established (Nock & Prinstein, 2004, p. 885). In addition, SMB often occurs in conjunction with other self-destructive behaviors, such as substance abuse and eating disorders. Thus, SMB is the result of a complex interaction of a variety of childhood, individual, and environmental risk factors. Assessment and diagnosis. It is often difficult to identify SMB since most individuals minimize their symptoms and are evasive about their injuries. In the Diagnostic and Statistical Manual of Mental Disorders (4 th ed.), SMB has no category of its own, but is a symptom of other disorders and is most associated with a diagnosis of borderline personality disorder (Liebenluft, Gardner, & Cowdry, 1987; Walsh & Rosen, 1988). Other diagnoses such as multiple personality

6 Understanding Self-Mutilation 6 disorder, major and minor depression, obsessive-compulsive disorder, eating disorders, schizophrenia, and anxiety disorders, to list a few, have also been associated with self-mutilation (Brittlebank et al., 1990; Darche, 1990, Favazza, 1989). Therefore, when assessing SMB, it is important to rule out other psychiatric conditions. Dallam (1997) suggests a thorough assessment of the individual s medical, psychiatric, and family history, as well as previous injuries, motives, methods, and process of self-injury, interaction patterns and relationships, current stressors and losses, and coping style. The practitioner should also assess risk of further self-injury or suicide, as well as depression and anxiety, which are often concurrent disorders. In addition, the practitioner needs to inquire about other self-damaging and addictive behaviors, such as anorexia or bulimia, substance abuse, and abusive relationships. Treatment and intervention. While treatment can be challenging and success elusive, recent data demonstrate that a multifaceted therapy approach that engages the child, family, and trusted primary care and mental health providers, significantly contributes to decreasing or eliminating self-cutting behavior (Machoian, 1998; Suyemoto & MacDonald, 1995). Derouin and Bravender (2004) conclude that the primary goals for adolescent self-mutilators are to decrease environmental stress by increasing the feelings of connectedness to parents and social circles, improve communication skills, develop effective measures of self-soothing that do not include self-harm, and improve mood and emotional regulation (p. 4). Therapies may focus on increasing support for the adolescent within and outside the family, improving family communication, and increasing options for control of the environment (Dallam, 1997; Favazza, 1998).

7 Understanding Self-Mutilation 7 Project Methodology A comprehensive review of the current literature, designed to inform a practical assessment and screening model, will address the need for counselling practitioners and clients to understand SMB so that an effective treatment program may be developed. A preliminary outline of this assessment and screening model, based upon research included in my initial literature review, will serve as a skeletal foundation to guide further research (see Appendix A). It is my intent to expand and provide details for this theoretical model as my research becomes more extensive. Therefore, the central purpose for conducting the literature review is to enhance practitioners knowledge and practice, organize the information, and provide a comprehensive understanding of what is known about SMB based upon the research findings. For this comprehensive literature review, it will be important to focus my research on the assessment and treatment domains of SMB, making connections, and critically synthesizing those findings, so that a practical orientation for this project will evolve. For this research, I will use online databases, such as PsychINFO, EBSCO host, OVID, and MedLine. I will also use books and websites to supplement my research. I will focus my search strategy by utilizing the terms selfmutilation in conjunction with assessment, treatment, diagnosis, interview, and identification. The primary research articles will then be evaluated and analyzed with reference to Mertens (1998) guidelines for evaluating qualitative and quantitative research. The results will be synthesized into an assessment and screening model for the practitioner to use as a resource to facilitate understanding and intervention. In order to ensure that the review is current, the majority of articles included will be published from Overall, I plan to conduct a

8 Understanding Self-Mutilation 8 more comprehensive search in a specific area of SMB (assessment and intervention) so that a useful assessment and screening model may be developed. It is hoped that current practitioners, school guidance counsellors, families and adolescents will benefit from this project. It will provide information and a model to facilitate the process of understanding and treatment. In this way, it is hoped that knowledge and guidance will decrease the initial negative reaction to SMB and the treatment process will be enhanced. Adolescents will benefit by seeking help from a knowledgeable and helpful practitioner, and parents will benefit by connecting to an informed practitioner. Potential Implications of Project Through the development of an assessment and screening model for counselling practitioners to use with adolescents who engage in SMB, it is my firm belief that practitioners, adolescents and their families will benefit. The practitioner will benefit in that this model serves as a resource that will enhance understanding, facilitate an initial assessment of the behavior, and provide the means to promote effective treatment. The adolescent will benefit in that he or she will initially have a helpful experience that will provide the foundation for establishing an effective working alliance. Adolescents will not only feel understood, but also their own understanding of their behaviors will be increased through an exploration of the role of SMB in their lives. Families will, in turn, benefit by being provided with current and factual information about SMB and with the hope of an effective intervention. As such, intervention can operate from a more meaningful stand at the onset, with the literature review and the assessment model facilitating an awareness and impetus for an efficient process of counselling intervention.

9 Understanding Self-Mutilation 9 References American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4 th ed.). Washington, DC: Author. Arnold, L., & Babiker, G. (1998). Counselling people who self-injure. In Zetta Bear (Ed.) Good Practice in Counselling People Who Have Been Abused, Bristol, Pennsylvania: Jessica Kingsley Publishers. Bravender, T. (2002). Adolescent medicine. Monograph Ed. No. 279, Home Study Self- Assessment Program. Laewood, KS: American Academy of Family Physicians, August, Brittlebank, A. D., Cole, A., Hassanyeh, F., Kenny, M., Simpson, D., & Scott, K. (1990). Hostility, hopelessness and deliberate self-harm: A prospective follow-up study. Acta Psychiatrica Scandinavica, 81, Dallam, S. J. (1997). The identification and management of self-mutilating patients in primary care. Nurse Practitioner, 22(5), , Darche, M. A. (1990). Psychological factors differentiating self-mutilating and non-selfmutilating adolescent inpatient females. Psychiatric Hospital, 21(1), Derouin, A. & Bravender, T. (2004). Living on the edge: The current phenomenon of self-mutilation in adolescents. The American Journal of Maternal/Child Nursing, 29(1), Dibrino, C.I. (1998). Self-mutilation in adolescence (Doctoral dissertation, Adler School Of Professional Psychology, 1998). Dissertation Abstracts International, 59, Favazza, A.R. (1998). The coming of age of self-mutilation. Journal of Nervous &

10 Understanding Self-Mutilation 10 Mental Disease, 186(5), Favazza, A. R. (1989). Why patients mutilate themselves. Hospital and Community Psychiatry, 40, Kehrberg, C. K. (1997). Self-mutilating behavior. Journal of Child and Adolescent Psychiatric Nursing, 10(3), Leibenluft, E., Gardner, D., & Cowdry, R. W. (1987). The inner experience of the borderline self-mutilator. Journal of Personality Disorders, 1(4), Levenkron, S. (1998). Cutting: Understanding and Overcoming Self-Mutilation. New York: W. W. Norton & Co. Lloyd, E.E. (1998). Self-mutilation in a community sample of adolescents (Doctoral dissertation, Louisiana State University, 1998). Dissertation Abstracts International, 58, Lloyd, E., Kelley, M.L., & Hope, T. (1997, April). Self-mutilation in a community sample of adolescents: Descriptive characteristics and provisional prevalence rates. Paper presented at the Annual Meeting of the Society for Behavioral Medicine, New Orleans, Louisiana. Machoian, L. (2001). Cutting voices: Self-injury in three adolescent girls. Journal of Psychosocial Nursing & Mental Health Services, 39(11), Mertens, D.M. (1998). Research methods in education and psychology. Thousand Oaks, CA: Sage. Nock, M. K., & Kazdin, A. E. (2002). Examination of cognitive, affective, and behavioral factors and suicide-related outcomes in children and young adolescents. Journal of Clinical Child and Adolescent Psychology, 31,

11 Understanding Self-Mutilation 11 Nock, M.K., & Prinstein, M.J., (2005). Contextual features and behavioral functions of self-mutilation among adolescents. Journal of Abnormal Psychology, 114(1), Ross, S., & Heath, N. (2002). A study of the frequency of self-mutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31, Suyemoto, K. L., & MacDonald, M. L. (1995). Self-cutting in female adolescents. Psychotherapy, 32, Walsh, K. (2002). Welcome advances in treating youth anxiety disorders. Contemporary Pediatrics, 9(66), Walsh, B. W., & Rosen, P. M. (1988). Self-mutilation: Theory, research and treatment. New York: Guilford. Zila, L. M. & Kiselica, M. S. (2001). Understanding and counseling self-mutilation in female adolescents and young adults. Journal of Counseling & Development, 79,

12 Understanding Self-Mutilation 12 Appendix A Assessment and Screening Model for SMB 1. Assessment and Initial Management. a. Suicide Risk b. Social, Psychological, and Motivational Factors c. Concurrent Diagnoses d. Assessment Tools 2. Treatment Approaches. a. Cognitive b. Behavioral 3. Resources a. Websites b. Organizations c. Books d. Newsletters