Examining the Spectrum from NonSuicidal SelfInjury to Suicide Finality Critical Issues Conference October 9 2015 Michael Riquino LCSW PrefaceWarnings I talk really fast its not because Im nervous its just the way I talk ID: 591996
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Understanding and Addressing Self-Injury: Examining the Spectrumfrom Non-Suicidal Self-Injury to Suicide Finality
Critical Issues Conference, October 9, 2015
Michael Riquino, LCSWSlide2
Preface/WarningsI talk really fast – it’s not because I’m nervous, it’s just the way I talkReferences to celebrities or pop culture are meant to inform – not to glamorizeI have a macabre sense of humor – I apologize for any unintentional crassness
This PowerPoint is available on my website:
www.addressingselfinjury.weebly.comSlide3
Spectrum/Overlapping ConstructsAnd the importance of considering semanticsSlide4
Transdiagnostic PerspectiveSelf-injury is diagnostically heterogeneous:Mood disorders (depression
, bipolar)
Anxiety disorders (GAD,
PTSD
)
Personality disorders (
borderline
, avoidant)
Eating disorders (
bulimia
,
anorexia
)
Substance
disorders
A note about child maltreatment:
62
% of individuals engaging in self-injury report some form of childhood
abuseSlide5
Self-Harm as an Umbrella TermSlide6
What is Self-Injury?Deliberate or intentional destruction of body tissue without suicidal intent
Other common labels include deliberate self-harm, parasuicidal behavior, self-mutilation, non-suicidal self-injury, and cutting
A note about use of the term “cutter” Slide7
Forms of Self-InjuryMost common forms:cutting (70-97%)banging or hitting (21-44%)burning (15-35%)
75% of individuals who engage in self-injury employ more than one method
Other forms include:
bone breaking
skin
picking
(dermatillomania)
hair
pulling
(trichotillomania)
biting and scratching
interfering with the healing of
wounds
(excoriation)Slide8
Prevalence of Self-Injury9% - 17% of adolescents in community samples28% - 46% of high school students reported at least one instance of self-injury in the last year40% - 80% of adolescent psychiatric patients
Average age of onset
between 12 and 15 years old (
as young as 6 and up to 24
)Slide9
Sociocultural ContextTattoos and piercings becoming mainstreamMormonism (58%) and Catholicism (10%)Please note, religion is typically a protective factorOlympic athletes – Kerri Strug, gold medalistRitual scarification, fasting and meditationEating disorders are no longer trendyPlease note, use of the word “trendy” is reductiveSlide10
Functions of Self-InjuryMost common functions:Emotion regulationAnti-dissociation/numbness
Anti-suicide
Self
-punishment
Interpersonal influence*
Other functions include:
Sense of control
Connecting mind and body
Sensation-seeking
Avoidance of internal pain
Distraction from flashbacks
*Less than 4% of adolescents who self-injure do so to get attention, yet this is the most common reason given by parents, teachers, and other adults to explain the behaviorSlide11
Self-Injury and Suicide50% of individuals in community samples and 70% of inpatients who engage in self-injury report having attempted suicide at least once A paradoxical relationship:Self-injury simultaneously serves as a coping mechanism for dealing with suicidal ideation and is a correlate of past and possible future suicide attempts Slide12
Self-Injury and Social MediaThe internet may be used as a support network and a coping mechanism, and can connect people who are socially isolatedThe internet may negatively influence vulnerable youth:Normalization of self-injurious behaviors
Access to suicide content and violent imagery
Creates a communication channel for bullying/harassment
Exposure to self-harm on the internet may be associated with potentially more dangerous methods of self-harm
Daine
, K.,
Hawton
, K.,
Singaravelu
, V., Stewart, A.,
Simkin
, S., & Montgomery, P. (2013). The power of the web: A systematic review of studies of the influence of the internet on self-harm and suicide in young people
. PLOS ONE 8,
e77555,
doi
: 10.1371/journal.pone.0077555Slide13
Combating StereotypesStereotypes are grounded in truth, but are ultimately false as they cannot be ascribed to any particular individualSelf-injurious behaviors are overly associated with “emo” or “scene” culture due to the lyrical content of such musical artists and the ascription of self-injury as a fad among “emos”Slide14
Suicide Variables/PatternsGender differences: Frequency vs. LethalityVulnerable populationsChildren and adolescentsElderly persons (19% of suicides vs. 12 % of population)LGBTQ youth (30% of suicides vs. 10% of population)Native Americans and other ethnic minoritiesReligiosity as a protective factor or a risk factorSlide15
Risk Factors & Protective FactorsRisk Factors vs. Warning SignsWarning signs indicate an immediate risk of suicide whereas risk factors indicate someone is at heightened risk for suicide, but indicate little or nothing about immediate riskWarning signs are only applicable to individuals whereas risk factors are found in individuals and communities Risk factors include prior suicide attempts, mood disorders, substance abuse, psychosis, and access to lethal meansWarning signs include threatening to hurt or kill oneself, seeking the means to kill oneself, hopelessness, increasing substance use, and dramatic mood changesSlide16
Risk Factors & Protective FactorsProtective FactorsCoping Skills and Personal TraitsDecision making, anger management, conflict resolution, problem solving and other coping skillsA sense of personal control over actionsA healthy fear of risky behavior and painHope for the futureConnectionsReligious/spiritual beliefs about the meaning and value of lifePositive relationships with family, friends, or other caring adultsResponsibilities at home or in the community
Physical health and a safe/stable home environmentSlide17
Columbia-Suicide Severity Rating ScaleSuicidal ideationWish to be dead, e.g., “Have you ever thought about being dead or what it would be like to be dead? Have you ever wished you were dead or wished you could go to sleep and never wake up? Do you wish you weren’t alive anymore?”Non-specific active suicidal thoughts, e.g., “I’ve had thoughts about killing myself”Active suicidal ideation with any means (not plan) without intent to actActive suicidal ideation with some intent to act, without specific plan
Active suicidal ideation with specific plan and intentSlide18
Columbia-Suicide Severity Rating ScaleSuicidal behaviorActual attempt, i.e., a potentially self-injurious act with at least some wish to die as a result of actHas subject engaged in non-suicidal self-injurious behavior?Has subject engaged in self-injurious behavior, intent unknown?Interrupted attempt, i.e., when the person is interrupted by any outside circumstance from starting the potentially self-injurious act; if not, actual attempt would have occurredAborted attempt, i.e., when person begins to take steps toward making suicide attempt, but stops themselves
Preparatory acts or behavior, i.e., acts or preparation towards imminently making a suicide attemptSlide19
Columbia-Suicide Severity Rating ScaleActual lethality/medical damage0 = No physical damage or very minor damage (e.g., surface scratches)1 = Minor physical damage (e.g., superficial burns; mild bleeding)2 = Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-degree burns; bleeding of major vessel)3 = Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose with reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures)4 = Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; third-degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area)
5. Death
Potential lethality (if actual lethality = 0)Slide20
Summing up the C-SSRSSuicidal ideation has four “parts” or “levels”Thoughts of wanting to dieNon-specific thoughts of killing selfSuicide plansIntent to dieSomewhat reductive, but helpful for conceptualization and communicating with adolescentsStanley Brown Safety TemplateSlide21
Spectrum/Overlapping ConstructsIntentBased on self-reportSubject to decayMethodsForms of self-injuryForms of suicideRisk of lethalitySlide22
Take-Home MessagesRespond with emotional neutrality – Don’t freak out!Reflect, Validate, Problem-solve
Addressing guilt vs. shame
Guilt can be
constructive because it
motivates us to change our behavior
Shame is always
destructive because it
contributes to feelings of worthlessness
Setting boundaries for physical safety
Focusing on underlying thoughts and feelingsSlide23
Ten Years LaterBeing present in the moment – the promise and potential of mindfulnessThe importance of self-acceptance and self-compassionThe potential for parents/caregivers to be the greatest sources of support – the role of psychoeducationInitial assessments – instilling hopeSlide24
Suicide Prevention ResourcesHope4Utah www.hope4utah.org Suicide Prevention Resource Center www.sprc.org Prevention Lifeline www.suicidepreventionlifeline.org
National Alliance on Mental Illness
www.nami.org
American Foundation for Suicide Prevention
www.afsp.org
Substance Abuse and Mental Health Services Administration
www.samhsa.org
Slide25
Online Self-Injury ResourcesCornell Research Program www.selfinjury.bctr.cornell.edu To Write Love On Her Arms www.twloha.com S.A.F.E. Alternatives
www.selfinjury.com
Secret Shame
www.selfharm.net
The Trevor Project
www.thetrevorproject.org
Rape, Abuse, & Incest National Network
www.rainn.org
Slide26
Self-Injury Book ResourcesTreating Self-Injury by Barent WalshThe Oxford Handbook of Suicide and Self-InjuryBodily Harm by Karen Conterio and Wendy Lader
A Bright Red Scream
by Marilee Strong
Helping Teens Who Cut
By Michael Hollander
Cutting
by Steven Levenkron
Bodies Under Siege
by Armando FavazzaSlide27
Selected References Conterio, K., Lader, W., & Bloom, J.K. (1998). Bodily harm: The breakthrough healing program for self-injurers. New York, NY: Hyperion.
Gratz, K.L. (2003). Risk factors for and functions of deliberate self-harm: An empirical and conceptual review.
Clinical Psychology: Science and Practice, 10,
192-205. doi: 10.1093/clipsy/bpg022.
Hollander, M. (2008).
Helping
teens
who cut: Understanding and ending self-injury
. New York, NY: The Guilford Press.
Klonsky, E.D. (2007b). The functions of deliberate self-injury: A review of the evidence.
Clinical Psychology Review, 27,
226-239. doi:10.1016/j.cpr.2006.08.002.
Klonsky, E.D., & Moyer, A. (2008). Childhood sexual abuse and non-suicidal self-injury: Meta-analysis.
The British Journal of Psychiatry, 192,
166-170. doi: 10.1192/bjp.bp.106.030650.
Klonsky, E.D., & Muehlenkamp, J.J. (2007). Self-injury: A research review for the practitioner.
Journal of Clinical Psychology, 63,
1045-1056. doi: 10.1002/jclp.20412.
Lang, C.M., & Sharma-Patel, K. (2011). The relationship between childhood maltreatment and self-injury: A review of the literature on conceptualization and intervention.
Trauma, Violence, & Abuse, 12,
23-37. doi: 10.1177/1524838010386975.
Nock, M.K., Teper, R., & Hollander, M. (2007). Psychological treatment of self-injury among adolescents.
Journal of Clinical Psychology, 63,
1081-1089. doi: 10.1002/jclp.20415.
Polk, E., & Liss, M. (2009). Exploring the motivations behind self-injury.
Counselling Psychology Quarterly, 22,
233-241.
Spinhoven, P., Slee, N., Garnefski, N., & Arensman, E. (2009). Childhood sexual abuse differentially predicts outcome of cognitive-behavioral therapy for deliberate self-harm.
The Journal of Nervous and Mental Disease, 197,
455-457.
Strong, M. (1998).
A bright red scream: Self-mutilation and the language of pain
. New York, NY: Penguin Books.