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Understanding Self-Injury Behaviors: An Introduction to Assessment and Treatment Stephanie Bonier, LCPC, CADC Clinical Therapist in the Discoveries Program
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Objectives • Identify self-injury behaviors and gain insight regarding the differences between self-injury behaviors and suicidal behaviors • Gain knowledge regarding basic tools for assessment, along with treatment components for self-injury behaviors • Obtain information regarding creating and implementing a self-injury protocol within the school setting • Gain understanding regarding basic Dialectical Behavioral Therapy techniques to utilize during individual and group sessions with students 3
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Self-injury is… How would you complete this sentence? What do you know already about self-injury?
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Myth or Fact? • Only females self-injure • Self-injury is a suicide attempt or failed suicide attempt • Only teenagers self-injure • Anyone who self-injures is crazy and should be locked up • Self-injury is just attention-seeking • Self-injury is untreatable
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Myth or Fact? • People who self-injure are manipulative • All people who self-injure have Borderline Personality Disorder • People who self-injure only cut themselves • Anyone who self-injures is part of the “Gothic” or “Emo” subgroups • People who self-injure enjoy the pain or they can‟t feel it • All people who self-injure have been abused 6
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What is Self-Injury? Self-injury is intentional, self-effective, lowlethality bodily harm of a socially unacceptable nature, performed to reduce psychological distress. “The deliberate, self-inflicted destruction of body tissue resulting in immediate damage, without suicidal intent and for purposes not culturally sanctioned.” - Cornell Research Program on Self-Injury and Recovery
Defining Self-Injury Behaviors • Self-injury is a behavior • Typically excludes: ‒ Piercings and tattoos ‒ Nail-biting ‒ Skin picking ‒ Hair pulling • Use of terminology ‒ Self-injury > Self-Harm
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Defining Self-Injury Behaviors • It can be anywhere on the body ‒ Most commonly located on the hands, wrists, stomach, thighs • A variety of objects can be used ‒ Most commonly used objects include razors, scissors, knives, lighters, fingernails, etc. • Severity of self-injury can vary dramatically ‒ Superficial ‒ Break skin surface ‒ Need medical attention 9
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Examples of Self-Injury Behaviors • • • • • • • • • •
Cutting **MOST COMMON** Scraping or scratching Burning Hitting self Head/Limb banging Biting Choking self Picking wounds Skin picking Embedding
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Levels of Severity of Self-Injury Behaviors • Cornell Research Program identifies three levels of severity ‒ High severity 11+ lifetime incidents 2+ forms; with one likely to cause severe tissue damage
‒ Moderate severity
2 to 10 lifetime incidents 2 to 3 forms; with one likely to cause bruising or light tissue damage
‒ Low severity
Fewer than 10 lifetime incidents 1 form that likely causes superficial tissue damage
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Demographics of Self-Injury • Age of onset ‒ Early onset can occur as early as 7 years of age ‒ Typical onset occurs around middle adolescents, between ages 12 and 15 • Co-morbidity with other disorders ‒ Childhood abuse and trauma, eating disorders, substance use, PTSD, Borderline Personality Disorder, depression, and anxiety disorders 12
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Demographics of Self-Injury • Gender ‒ Studies vary regarding prevalence related to gender differences ‒ Studies have determined that methods vary between genders • Race/Ethnicity ‒ Statistics are uncertain ‒ May be more common among Caucasians - Some studies show contradictory information, a well as varied prevalence depending on region 13
Demographics of Self-Injury • Sexual Orientation ‒ Studies suggest higher prevalence rates within sexual minority groups - Particularly bisexual females
• Socio-Economic Status ‒ Strong links between self-injury and eating disorders sometimes leads to the assumption that middle and upper income individuals struggle more ‒ Additionally, there are strong links between self-injury and trauma which may be more prevalent in lower-income populations 14
Prevalence of Self-Injury • 12% to 24% of high school aged and young adults reported having self-injured in their lives ‒ About 25% of individuals who reported a history of self-injury have only done so once during their lifetime • 6% to 8% of young adults and adolescents report current, chronic self-injury
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Prevalence of Self-Injury Behavior • Worldwide estimates ‒ Adolescents: 17% ‒ Young Adults: 13% ‒ Adults: 6% • U.S. estimates ‒ Adolescents: 12-38% ‒ Young Adults: 12-20% ‒ Adults: 2-8%
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Additional Self-Injury Statistics • Early 1980s – 400 per 100,000 people self-injured ‒ Late 1980s – 750 per 100,000 people self-injured
• Late 1990s – 1,000 per 100,000 people self-injured • People are 90 times more likely to self-injure than commit suicide • People are 5.5 times more likely to self-injure than abuse alcohol • About 12 million people in the United States have self-injured • In a study conducted in 2006 of 3,000 college students, it showed that 17% had self-injured at some point in their lives
Self-Injury Statistics Across the Lifetime • Youth in Middle School and High School ‒ Onset of self-injury: 59% of the sample reported that they started in 7th or 8th grade 11.5% 9th grade 24.6% before 6th grade
‒ Female to male ratio was 2:1
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Self-Injury Statistics Across the Lifetime • Adolescents and Young Adults in College ‒ This population is generally composed of the people that started harming themselves when they were in middle school or high school ‒ In a study conducted by Favazza and Rosenthal, they reported that 12% of a college-aged sample have self-injured during their lifetime 19
Self-Injury Statistics Across the Lifetime • Adults ‒ Briere and Gil conducted a study which found that self-injury is rare in the general adult population
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Self-Injury v. Suicide • There are 9 major points of distinction: 1. Intent 2. Level of Physical Damage and Potential Lethality 3. Frequency of Behavior 4. Multiple Methods 5. Level of Psychological Pain 6. Constriction on Cognition 7. Helplessness and Hopelessness 8. Psychological Aftermath of the Self-Injury Incident 9. The Core Problem 21
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Self-Injury v. Suicide: Intent • Self-Injury ‒ Modify consciousness ‒ Relieve painful feelings ‒ Wants to live another day • Suicide ‒ Terminate consciousness ‒ Stop the psychological pain ‒ Will do whatever it takes to make the pain go away permanently 22
Self-Injury v. Suicide: Level of Physical Damage and Potential Lethality •
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Self-Injury ‒ Common methods include cutting, burning, selfhitting, interfering with wound healing, hair pulling, and bone breaking ‒ These behaviors are alarming, and typically not life threatening Suicide ‒ Research shows 7 basic methods used; including shooting, hanging, overdose/poisoning, jumping, cutting, drowning, and transportation related ‒ 98.6% of individuals who die by suicide do so by other means than cutting
Statistic is even higher for ages 15 to 24 (99.6%)
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Self-Injury v. Suicide: Frequency of Behavior •
Self-Injury ‒ Occurs at a much higher rate than suicide attempts ‒ Common reported frequency of the behavior can fall between 20 to 100 times per year
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Frequency may be very difficult to accurately count
Suicide ‒ Usually not done recurrently or frequently
An individual may attempt suicide once or twice during a particularly difficult, and stressful, time during their life Recurrent attempts are likely related to serious and persistent mental illnesses
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Self-Injury v. Suicide: Multiple Methods • Self-Injury ‒ Most individuals will utilize multiple methods to self-injure ‒ Typically related to preference and circumstance • Suicide ‒ Tend to use overdose as their main method to attempt suicide and typically stay with that method 25
Self-Injury v. Suicide: Level of Psychological Pain • Self-Injury ‒ Pain is “intense and uncomfortable” and “interruptible and intermittent” • Suicide ‒ “Unendurable, persistent pain” typically drives a suicide attempt ‒ Pain wears down the person and creates profound distress
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Self-Injury v. Suicide: Constriction on Cognition • Self-Injury ‒ Disorganized thought patterns ‒ Typically view that they have options and make the choice to utilize self-injury • Suicide ‒ All-or-nothing option ‒ Thinks in a constricted and narrow way ‒ “If this happens, I will kill myself”
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Self-Injury v. Suicide: Helplessness and Hopelessness • Self-Injury ‒ Typically do not experience helplessness and hopelessness • Suicide ‒ Experience high levels of helplessness and hopelessness ‒ “I‟m no good, everything around me is terrible, and nothing will ever change”
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Self-Injury v. Suicide: Psychological Aftermath of the Self-Injury Incident • Self-Injury ‒ Receive immediate relief after the behavior • Suicide ‒ Do not feel any better after surviving an attempt, and will often feel themselves feeling worse ‒ Persistent, intense pain, and high-lethality intent after the failed attempt 29
Self-Injury v. Suicide: The Core Problem •
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Self-Injury ‒ Core problems could include body image issues due to experience many negative attitudes about themselves ‒ Additional core problems could be a combination of intense stress, peer influences, and inadequate soothing skills Suicide ‒ Usually a combination of sadness, depression, and rage about their pain ‒ Must work to find the specific source of their pain in therapy
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Self-Injury Behavior Warning Signs • Unexplained scars, cuts, bruises, or burns • „Inappropriate clothing‟ and/or excessive accessories ‒ Wearing long-sleeved shirts or long pants when the weather or occasion calls for something lighter ‒ Bangles, bracelets, or wristbands • Broken disposable razors • Collections of cutting paraphernalia ‒ Pencil sharpeners, pocket knives, pencils/pens, scissors, broken glass
Self-Injury Behavior Warning Signs • Knives, scissors, or tools found in their room • Bloodied wads or tissue or toilet paper, or blood on towels, facecloths, etc. • First-aid supplies or antiseptic ointments near the bed or being used more in the bathroom • Traces of blood on clothing • Rubbing arms through sleeves • The emotional roller coaster
Self-Injury Behavior Warning Signs • Unwilling to participate in events that require less body coverage ‒ Example: swim/gym class • Frequent, odd breaks/absences ‒ Example: leaving class for long periods of time • Difficulty verbalizing or expressing emotional needs to others • Increased isolation from peers, social groups, and family 33
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Self-Injury Behavior Warning Signs • • • •
Physically or emotionally distant/preoccupied Low self-esteem Difficulty managing emotions Difficulty functioning in various areas of life ‒ School, home, work, social groups, etc. • Sensitivity to rejection ‒ Examples: peer rejection, romantic rejection, academic rejection
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Why People Begin to Self-Injury Behaviors • They experience of major family dysfunction ‒ Sexual abuse ‒ Physical abuse ‒ Loss and divorce ‒ Exposure to family violence ‒ History of family alcoholism ‒ History of family mental illness and suicide • Invalidating home environment • Cultural factors • Other stressors including relationships, school, and work • They see others do it • They may accidently stumble upon it
Functions of Self-Injury Behaviors • Affective imbalance ‒ Cope with uncomfortable feelings ‒ Change emotional pain to physical pain ‒ Feel something ‒ Gain a sense of control ‒ Relieve stress or pressure ‒ Deal with frustration ‒ Deal with anger • Social communication and expression ‒ Communicate to others that something is wrong and that help is needed ‒ Hurt or shock others ‒ Fit in with friends 36
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Functions of Self-Injury Behaviors • Self-retribution and deterrence ‒ Punish self ‒ Manage self-loathing ‒ Avoid hurting self in other ways, such as suicide • Sensation seeking ‒ Unable to control urges ‒ It feels good ‒ Rush or surge of energy ‒ Like the way it looks 37
Other Functions of Self-Injury Behaviors • Other functions include: ‒ Distract from other problems ‒ Counter dissociation ‒ Boundary setting between self and others ‒ Influence other‟s behaviors
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Self-Injury Behavior as an Addiction • Stimulates endogenous opioid system • Tolerance, dependency, and withdrawal symptoms can develop overtime • It can weaken your other coping skills • Doesn‟t solve your problems and tends to create additional problems ‒ Relationship problems ‒ Self-respect problems ‒ Physical problems • Can be dangerous and even lethal
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Time for a Break!
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What Next? How do we apply this information to the school setting?
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Current Protocol/Procedure How do you currently handle self-injury at your school?
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Why have a Self-Injury Protocol? • Helps guide responses to situations that may be uncomfortable or difficult to manage • Helps assure legal responsibilities and liabilities are addressed ‒ As well as school policy and procedure • Is systematic and strategic rather than being based off of emotion
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Functions of the Self-Injury Protocol • • • • • •
Identify ways to identify self-injury Identify ways to assess self-injury Designate a point person Develop a protocol for contacting parents Identify ways to manage active self-injury Develop external referral resources and determine when to use them • Provide education to staff and students about self-injury 44
First Step to Developing a Self-Injury Protocol • Start with your school crisis team ‒ Crisis team should consist of guidance counselors, social workers/counselors, school psychologists, nurses, teachers, and/or administrators • Pick a point person ‒ This is the person that will be the main liaison between the student, parents, and school • Obtain training about self-injury 45
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Responsibilities of Your Point Person • Responds to self-injury disclosures • Is a resource to staff • Makes contact with self-injuring student ‒ Escorts the student to the nurse for medical assessment and care • Assess for potential suicidal ideations or intent • Connect with parents, impacted staff and peers, and outside referrals • Establish a relationship with the student 46
Identifying and Detecting Self-Injury • There are several ways that one may discover that a student is self-injuring ‒ Student may self-disclose to staff ‒ One student may notify a staff member about another student ‒ Staff may notice signs and symptoms of self-injury ‒ Parents may contact the school and disclose information ‒ Outpatient providers may contact school and disclose information 47
Assessing for Self-Injury Behaviors • Assessment should be conducted by the designated point person and school nurse if there are wounds that require medical attention • Assessing self-injury ‒ A comprehensive assessment would target information regarding location of self-injury, frequency, severity, method, and precipitating events • Assessing for suicide ‒ Students may or may not be experiencing suicidal ideations, however it is important to assess for additional safety concerns 48
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Assessing for Self-Injury Behaviors • Areas to assess: ‒ Behavior ‒ Function ‒ Recency and frequency ‒ Age of onset ‒ Wound locations ‒ Severity ‒ Practice patterns ‒ Habituation and interference in life ‒ Treatment experiences 49
Assessing for Self-Injury Behaviors • Areas to assess: ‒ Behavior - Specific way(s) that the individual harms themselves
‒ Function - Why the individual harms themselves
‒ Recency and frequency ‒ Age of onset ‒ Wound locations 50
Assessing for Self-Injury Behaviors • Areas to assess: ‒ Severity - Related to if medical attention was ever needed
‒ Practice patterns - Routines or rituals associated with self-injury
‒ Habituation and interference in life - Assesses tolerance, intensity, and lack of control; along with life interference
‒ Treatment experiences - Related to participation in treatment 51
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Protocol for Contacting Parents and Supports • Ideally, it is preferred, and encouraged, that the student call their parents and disclose information regarding their self-injury behaviors ‒ If the student is reluctant, the point person needs to take responsibility and contact the family • School meetings ‒ After disclosure, it is beneficial, and recommended, that the family attend a school meeting to discuss ways to manage potential future self-injury 52
Providing Parents with Education • In order to ease anxiety and fears of the students‟ parents, it is recommended that the point person provide them with resources regarding self-injury • These resources should include: ‒ General education regarding self-injury ‒ Effective ways to respond to self-injury ‒ Referrals for possible outpatient therapy or higher levels of care 53
Providing Parents with Support • Encourage parents to initiate outpatient therapy for their child • Begin to process and validate feelings that they may be experiencing ‒ Guilt ‒ Dismissiveness ‒ Anger
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External Referrals and When to Use Them • Each point person should be responsible for maintaining a list of referrals to provide families with ‒ These referrals should include hospitals (both inpatient and outpatient programs), individual and family therapists, and group therapists • Outpatient referrals are recommended to allow the student to learn additional ways to manage self-injury urges and behaviors and not interfere with school 55
Self-Injury Training at Your School • Who should be trained on self-injury? ‒ ALL teachers and ANYONE who comes into contact with students on a regular basis • Trainings should include: ‒ Ways to identify self-injury ‒ Symptoms/Warning signs of self-injury ‒ Difference between self-injury and suicide ‒ Ways to respond to self-injury 56
Putting Your Protocol Into Action • Look for possible self-injury warning signs • Make contact with your point person to begin process of additional assessment and care ‒ Contact person will: Assess self-injury Assess for potential suicidal ideations or intent Determine risk Contact parents
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Responding to Self-Injury Disclosures • Be calm, kind, and non-judgmental • Use „I-statements‟ • „Respectful curiosity‟ ‒ State of awareness that consists of genuine curiosity and willingness to understand and know combined with attention on respecting the individual who has engaged in selfinjury ‒ Respectful to ask the self-injurer if you can ask questions 58
‘Respectful Curiosity’ • Examples ‒ Why do you think self-injury works for you? ‒ How does self-injury make you feel? ‒ How do you feel after? ‒ What are some reasons you might want to to stop self-injuring? ‒ Is there anything stressing you out right now that I can help you with? ‒ What are some reasons it would be hard to stop self-injuring? 59
Now What? Now you have gained information to better understand self-injury behavior, and can identify it within your school; so what do we do next?
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Treatment for Self-Injury Behaviors • Dialectical Behavioral Therapy (DBT) ‒ Cognitive approaches • Exposure/Trauma treatment • Individual therapy • Group treatment • Family therapy • Psychopharmacology
Dialectical Behavioral Therapy • Empirically proven to be successful with individuals who self-injure; one of the most successful models for treating self-injury behaviors • Used for individuals who struggle with controlling emotions and behaviors • Aims to reduce “target” behaviors and increase use of more skillful behaviors • Helps to create a life worth living
Dialectical Behavioral Therapy • Skills taught fall into one of five modules: ‒ Mindfulness ‒ Emotion Regulation ‒ Interpersonal Effectiveness ‒ Distress Tolerance ‒ Walking the Middle Path • In addition to skills it is important to utilize: ‒ Diary/Skills cards ‒ Behavior chain analyses 63
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DBT: Mindfulness
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DBT: Mindfulness • Function is to increase our awareness of our thoughts, feelings, and urges in the moment to promote more effective decision making • “Pay attention with intention, to the present moment while noticing and letting go of judgments.” • Is at the core of ALL DBT skills and needs to be taught first before moving on to other modules 65
DBT: Mindfulness Mind States • Influence decision making • No „good‟ or „bad‟ mind state
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DBT: Mindfulness HOW
WHAT
Observe: Watch wordlessly, or just notice your experience in the moment.
One-Mindfully: Do one thing at a time.
Describe: Use facts; not interpretations. Talk about what you are observing as if you are someone who has never seen that thing before.
Non-Judgmentally: Acknowledge effective and ineffective, helpful versus harmful instead of „good‟ and „bad‟ and „positive‟ and „negative‟.
Participate: Throw yourself into the present moment; full immersion in an activity.
Effectively: Doing what works, even if it is not what we „want‟ to do. Acting skillfully versus acting solely on emotions.
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DBT: Mindfulness
Time for a Mindfulness Exercise!
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DBT: Emotion Regulation • Set of skills to improve our ability to decrease mood swings, emotional intensity, and mooddependent behaviors • Work toward taking charge of our emotions by: ‒ Understanding our experienced emotions ‒ Reducing emotional vulnerability to unwanted emotions ‒ Reducing frequency of unwanted emotions ‒ Stop or reduce unwanted emotions once they start 69
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DBT: Emotion Regulation • Skills include: ‒ ABC PLEASE ‒ Ride the Wave ‒ Opposite Action to Emotion
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DBT: Emotion Regulation
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DBT: Interpersonal Effectiveness • Goal of these skills is to increase effective, assertive, communication in order to build and maintain healthy relationships • Three types of effectiveness are focused on ‒ Objective ‒ Relationship ‒ Self-respect
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DBT: Interpersonal Effectiveness • Skills include: ‒ DEAR MAN ‒ GIVE ‒ FAST ‒ THINK
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DBT: Interpersonal Effectiveness
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DBT: Interpersonal Effectiveness
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DBT: Distress Tolerance • Set of skills to decrease impulsivity • Skills help us tolerate painful/crisis experiences ‒ Pain is part of life that cannot be avoided - Suffering is an option
‒ Prevents us from acting on impulsive urges by using our skills • Crisis survival skills • Function of these skills is to get us to a place where we can access and use wise mind 76
DBT: Distress Tolerance • We will only use these skills when we are in crisis! ‒ Using these skills when we are not in crisis will make them less effective when we are actually in crisis! • If we use these skills when we are not in crisis, we are teaching ourselves: ‒ We are in crisis when we are not ‒ We cannot tolerate painful, intense emotions
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CRISIS
8 7 6 5 4 3 2 1 0
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DBT: Distress Tolerance • Skills include: ‒ ACCEPTS - Distraction
‒ ‒ ‒ ‒ ‒ ‒
IMPROVE the Moment Self-soothe Pros and Cons Radical Acceptance Turning the Mind Willingness
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DBT: Distress Tolerance
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DBT: Distress Tolerance
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DBT: Distress Tolerance • Radical Acceptance ‒ Accepting things that you cannot change • Turing the Mind ‒ Making the choice to accept something after noticing that you are not accepting reality • Willingness ‒ Allowing the world to be what it is and participating fully, being effective, and listening to Wise mind to make a decision 81
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DBT: Walking the Middle Path • Set of concepts that focuses on replacing „either-or‟ with „both-and‟ thinking ‒ Increases the ability to see the „gray‟ area • Helps us make room for compromise and see different perspectives of situations • Developed to address common struggles that teens and their parents encounter
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DBT: Walking the Middle Path • Concepts include: ‒ Dialectics ‒ Validation ‒ Behavior change
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DBT: Walking the Middle Path
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DBT: Walking the Middle Path
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DBT: Diary/Skills Cards • Card utilized on a day-to-day basis to track urges and actions of target behaviors • Card usually tracks the following: ‒ Date/Time and location ‒ Vulnerabilities to emotion mind ‒ Prompting event ‒ Feelings ‒ Intensity of urge and if action was taken ‒ What the urges are telling you ‒ Skills that were used, if any 86
DBT: Behavior Chain Analyses • Step-by-step breakdown of thoughts, feelings, and behaviors associated with urges, or actions, related to target behaviors • How to: ‒ Start with identifying vulnerabilities to emotion mind ‒ Prompting event ‒ Thought Feeling Behavior • Once completed this activity allows the student to see possible patterns that lead to urges or engagement in target behaviors ‒ As well as when, and how, to use more effective skills 87
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DBT: Behavior Chain Analysis Example •
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Vulnerabilities to emotion mind: Tired, Lonely, Storms outside, Didn‟t eat dinner Prompting event: Best friend stopped talking to me
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Thought: “I just need to feel better.”
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Feeling: Sad, worthless, angry
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Behavior: Self-injured
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Thought: “Oh, that‟s better.”
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Thought: “What did I do wrong?‟
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Feeling: Relief
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Feeling: Worthless, sad, anxious
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Behavior: Cleaned up tools
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Behavior: Paced in bedroom •
Thought: “Oh no, why did I do that?”
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Thought: “Why do I always ruin things?”
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Feeling: Guilt and shame
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Feeling: Worthless, angry, sad
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Behavior: Began crying
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Behavior: Looked for self-injury tools •
Thought: “I keep messing things up”
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Feeling: Worthless, hopeless
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Behavior: Isolated self
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Implementing DBT in the School Setting • DBT is a combination of group-based education and individual therapy • Within the school setting DBT may look like: ‒ Weekly group-based DBT skills training ‒ Individual sessions with students to process diary/skills cards and use of skills • Groups can run anywhere from 30 to 60 minutes
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Step-by-Step Manual to Facilitate DBT in the School Setting
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Treatment of Self-Injury at Linden Oaks Hospital
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Discoveries Program at Linden Oaks • Treatment program focused on the treatment of self-injury behaviors in conjunction with other mental health diagnoses ‒ IOP and PHP levels of care are offered • Program earned The Gold Seal of Approval from The Joint Commission
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Discoveries Program at Linden Oaks • Program consists of: ‒ Daily group therapy ‒ Daily skills groups ‒ Daily expressive therapy ‒ Individual therapy (once or twice per week) ‒ Family therapy (once per week) ‒ Multi-family group (once per week) ‒ Body image group (once per week) ‒ Regular psychiatric support provided by nursing staff, psychiatrists, and physician assistants/advanced nurse practitioners 93
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Ways to Provide Reassurance During Treatment • Explain that the path to recovery is bumpy, and not to get discouraged • Try avoiding the „abstinence violation effect‟ • Validate that it is okay to miss self-injury • Discuss the beliefs about the skills because they matter as much as the skills ‒ What are the student‟s attitudes about the skills?
Questions?
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Upcoming Training at Linden Oaks Non-suicidal Self• Training will consist Injury: An Evidenceof information Based Update on presented in this Assessment and presentation, as Treatment well as additional training regarding • December 9, 2016 utilizing DBT • 9 AM to 12:15 PM approaches in • 1335 N. Mill St., treatment Naperville, IL 60563 96
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Resources for Professionals
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Resources for Professionals
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Resources for Professionals
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Resources for Professionals
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Resources for Professionals and Parents
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Resources for Parents
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References • Bubrick, K., Goodman, J. & Whitlock, J. (2010). Non-suicidal selfinjury in schools: Developing and implementing school protocol. [Fact sheet] Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults. Retrieved from http://crpsib.com/userfiles/NSSI-schools.pdf • Caicedo, S. & Whitlock, J.L. (2009). Top misconceptions about self-injury. The Fact Sheet Series, Cornell Research Program on Self-Injury and Recovery. Cornell University. Ithaca, NY. • Gratz, K. & Chapman, A. (2009). Freedom from Self-Harm: Overcoming Self-Injury with Skills from DBT and Other Treatments. Oakland: New Harbinger Publications. • Rathus, J.H. & Miller, A.L. (2015). DBT skills manual for adolescents. New York City: The Guilford Press. • Swannell, S.V., Martin, G.E., Page, A., Hasking, P., & St. John, N.J. (2014). Prevalence of nonsuicidal self-injury in nonclinical samples: Systematic review, meta-analysis and meta-regression. Suicide and Life-Threatening Behavior, 2, 1-31. 103
References • Walsh, B. W. (2005). Treating Self-Injury: A Practical Guide. New York City: The Guilford Press. • Whitlock, J. (2010). What is self-injury? [Fact sheet] Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults. Retrieved from http://www.selfinjury.bctr.cornell.edu/factsheet_aboutsi.asp • Whitlock, J. L., Exner-Cortens, D. & Purington, A. (under review). Assessment of non-suicidal self-injury: Development and initial validation of the non-suicidal self-injury assessment tool (NSSIAT). Psychological Assessment. • Whitlock, J. L., Muehlenkamp, J., Eckenrode, J. (2008) Variation in non-suicidal self-injury: Identification of latent classes in a community population of young adults. Journal of Clinical Child and Adolescent Psychology. 37(4). 725-735. • Whitlock, J. & Purington, M. (2013). Respectful curiosity. The Practical Matters series, Cornell Research Program on Self-Injury and Recovery. Cornell University. Ithaca, NY 104
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