Self Care Without Injury

1
Self Care Without Injury

• Canadian Counselling and Psychotherapy
  Association (CCPA) Annual Conference
• May 11-14, 2010
• Charlottetown, Prince Edward Island
• Presented By
• Nancy Buzzell, Ph. D., Licensed Psychologist
• University of New Brunswick Counselling Services
• Sarah Smith, Research Assistant
• Mount Allison University

2
As Laura entered her house she slammed the door
behind her. It had been a bad day, a very bad
day. Things at school had been terrible. As
Laura locked the door to her bedroom, she was so
angry that her whole body was shaking. All she
wanted to do was cry, but no tears would come.
Laura knew what she needed to do to feel better.
She took a small wooden box from under her bed.
Carefully lifting its lid, she removed the
contents, a single edged razor blade and a packet
of gauge bandages. Sitting on the carpeted floor,
gently rocking back and forth, she stared at the
silver blade in her hand. She needed to do it,
she told herself. It was the only way she could
feel better, feel normal again. Laura felt no
pain as she made the first of several cuts on her
left forearm. She watched as the blood spilled
from the cuts and dripped down her arm. It felt
warm and soothing on her cold skin. After
cutting herself in three or four places, Laura
wiped the blade clean with a piece of gauze and
placed it back in its box. She wrapped her
wounds tightly with the bandages, only then
feeling the sting. Although she felt tired and
drained, she also felt much better. Cutting
herself had worked, just as it always did.
Alderman, T. (1997). The scarred soul.
Oakland, CA Harbinger Publishers.
3
Self Injurious Behavior
All behavior involving the deliberate infliction
of direct physical harm to ones body without the
intent to die.
Simeon, D., Favazza, A. (2001).
Self-Injurious behaviors Phenomenology and
assessment. In Simeon E. Hollander (Eds.),
Self-injurious behaviors Assessment and
treatment (pp. 1-28). Washington, DC American
Psychological Association.
4
Self Injurious Behavior (SIB)

• Hitting/bruising (3)
• High risk activity
• Needle sticking
• Picking
• Skin picking
• Starving self
• Other (3)

• Breaking bones
• Burning (8)
• Biting
• Cutting (86)
• Scratching
• Hair pulling
• Head Banging

Gratz, K. L.. (2006). Risk factors for
deliberate self-harm among female college
students The role and interaction of childhood
maltreatment, emotional in-expressivity and
affect intensity/reactivity. American Journal of
Orthopsychiatry, 76 (20), 238-50.
5
Historical Trends

• Before 1990 Prevalent among individual with
  serious mental health issues and abuse/trauma
  backgrounds
• After 1990 Prevalent among school age
  children, adolescents university students
• Rate has risen by 150 over the last 20 years
  across a broad spectrum of society

Enns, K. (2008). Self injury behaviour in
youth Issues and strategies. Winnipeg, MB
Crisis Trauma Resource Institute Inc.
6
Who Does It Affect?
Percent Population Researchers 21 Clinical F/M)
Briere Gil (1998) 7 University
F/M) Gollust et al (2008) 38 University
(F/M) Gratz et al (2002) 37 University
(F) Gratz (2006) 44 University (M) Gratz
Chapman (2007) 13.89 High School (F) Ross
Heath (2003) 13.9 Community (F) Ross et al
(2009)
Rates of SIB are estimated to be between 12-38
7
Meta-analysis 8 Functions of Self Injury
(Cutting)

• Behavioral or the reinforcement of destructive
  behavior the linking of injury with self care
• Systemic or a way to express dysfunctional
  family or environment
• Suicidal or a suicide replacement
• Sexual or a result of conflicts over sexuality
  menarche

Suyemoto, K. L., MacDonald, M.L. (1995). Self
cutting in female adolescents. Psychotherapy
Theory, Research, Practice, Training. 32(1),
162-171.
8
Meta-analysis 8 Functions of Self Injury
(Cutting)

• Expression or a need to express or externalize
  overwhelming of anger, anxiety or pain
• Control or an attempt to control affect or need
• Depersonalization or a way to end or cope with
  not feeling present in ones own body
• Boundaries or an attempt to create distinction
  between self others

Suyemoto, K. L., MacDonald, M.L. (1995). Self
cutting in female adolescents. Psychotherapy
Theory, Research, Practice, Training. 32(1),
162-171.
9
General Risk Factors

• Feelings of powerlessness
• Feelings of being alone or isolated
• Difficulty recognizing/communicating feelings
• Few, if any, alternative coping behaviours
• Few self care or self soothing skills
• History of physical, sexual or mental abuse
• A likable, sometimes high achieving person with
  other problems.

Levenkron, S. (1997). Cutting Understanding
overcoming self mutilation. NY WW Norton
Company.
10
Specific Risk Factors
Characteristic Researchers Depression and
anxiety Hoff and Muehlenkamp (2009) Peer
invalidation Adrian (2010) Family
invalidation Adrian (2010) Academic
difficulties Mahadevan, Hawton Casey
(2010) Disordered eating Ross, Heath Toste
(2009) History of drug use Saules, Cranford
Eisenberg (2010) Sexuality Identity Saules,
Cranford Eisenberg (2010)
11
Social Context

• Recent research with university students who
  self-injure found that
• 43.6 of students reported that their behaviour
  was learned socially
• 86 of participants knew someone who self
  injured
• 74 had at least one friend who self injured
• 65 had talked to their friends about it
• 17.4 had engaged in it in front of friends
• 4.3 had engaged in it as a group with friends

Heath, N. L., Ross, S., Toste, J. R., Charlebois,
A. Nedecheva, T. (2009) Retrospective analysis
of social factors and non suicidal self-injury
among young adults. Canadian Journal of
Behavioral Science, 41, 180-186.
12
The Dissociation Factor
Dissociative Disconnected from parents, others
/or self. Not secretive about cutting at
times damages self in full view of others.
Attention is gratifying (secondary gain) in its
own right.

• Non-Dissociative
• Physical pain becomes a cure for emotional pain.
  Usually starts with feelings of anger, anxiety or
  panic. Person stumbles upon self injury and
  discovers it relieves their emotional state.
  Instant relief. Endorphin rush.

Levenkron, S. (1997). Cutting Understanding
overcoming self mutilation. NY WW Norton
Company.
13
Often Starts on an Impulse

• May start because of others in life who are
  self injuring
• May learn about self injury through tv shows,
  music videos, chat rooms
• May be accidental injury then person felt
  soothed
• May be result of extreme agitation/rage
  becomes pattern of self soothing

Enns, K. (2008). Self injury behaviour in
youth Issues and strategies. Winnipeg, MB
Crisis Trauma Resource Institute Inc.
14
Self Assessment Tool

• If I do this, will it hurt or harm my body? If I
  answer no would other people agree with me?
• If I do this, will I need help coping with the
  repercussions? Will I need to see a doctor,
  nurse, counsellor?
• If I do this, will the people I care about be
  upset? Frustrated? Frightened? Appalled?
• If I do this, will I lose an opportunity to reach
  my goals in life? Drop out of school? Miss an
  important opportunity?
• If you answer yes to just one, you are self
  harming.

Haswell, D., Graham, M. (2008). 5th Edition.
Overcoming self-abuse. Hamilton, ON S.A.F.E.
in Canada.
15
Clinical Assessment

• Frequency, duration, severity, medical history
  possible complications
• Reasons or purpose of SIB
• Determining clients stopping point
• Education about function (both ve -ve)
• Providing appropriate alternatives
• Ever thought about suicide?

Wester, K. Trepal, H. (2005). Working with
clients who self injure Providing alternatives.
Journal of College Counseling, 8, 180-189.
16
Why People Say It Works

• It calms me person down
• It helps me feel more in control
• It makes me feel alive

Haswell, D., Graham, M. (2008). 5th Edition.
Overcoming self-abuse. Hamilton, ON S.A.F.E.
in Canada.
17
Why We Think It Works

• Expresses feelings
• Releases negative emotions tension
• Makes emotional pain clearer
• Punishment
• Ends dissociation
• Results in a rush or a high
• Communicates something to other people

Gratz, K. Chapman, A. (2009). Freedom from
Self-Harm. Oakland, CA New Harbinger Publishers.
18
How it Works

• Like other injuries, it brings about the
  release of endorphins which are natural pain
  killers that calm down the central nervous
  system.
• It triggers (or ends) dissociation which is the
  minds way of producing a state of trance in
  which emotion pain can be disregarded.

Haswell, D., Graham, M. (2008). 5th Edition.
Overcoming self-abuse. Hamilton, ON S.A.F.E.
in Canada.
19
Reasons it Doesnt Work

• Undermines a persons mental, physical, social
  spiritual well-being
• Does nothing to solve problem(s)
• Offers only temporary relief
• Often followed by guilt shame

Haswell, D., Graham, M. (2008). 5th Edition.
Overcoming self-abuse. Hamilton, ON S.A.F.E.
in Canada.
20
www.safeincanada.org
E
Safe No trigger Ascending Starting to feel
triggered Feeling Out of control urge to self
injury Extremely unsafe strong urge to self
injure
SAFE Scale
F
A
S
Baseline
Trigger
Baseline
Self abuse does not allow the person to return to
baseline. Next time person start s off at a
higher trigger point.
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Addiction Model
Negative Emotions Alienation, Anger, Depression,
Frustration, Rejection, Sadness
Negative Effects Shame, guilt, depression
Tension Inability to control emotions thoughts
of self injury
Positive Effects Endorphins present, tension
negative emotions reduced
Dissociation Coping mechanism to reduce tension
later physical pain
Self Injury Burning, cutting, hitting, pulling
hair, scratching
Alderman, T. (1997). The scarred soul.
Oakland, CA Harbinger Publishers.
22
Questions We Can Ask

1. Think back to a time when you self injured. List
   three of the most intense emotions you had before
   you acted.
2. Describe how you felt when you began to think
   about hurting yourself. Did your feelings change
   as you got closer to injuring yourself?
3. Describe what you went through when you self
   injured. Did your feelings change throughout the
   process?

Alderman, T. (1997). The scarred soul.
Oakland, CA Harbinger Publishers.
23
More Questions
4. What happened after you hurt yourself. How
did you feel? Calm? Tired? Peaceful?
Anxious? 5. List the ways your self injury
contributed to a feeling of relief. How do you
define relief? 6. How long did it take after
hurting yourself to feel bad again?
Alderman, T. (1997). The scarred soul.
Oakland, CA Harbinger Publishers.
24
How Does it Function for the Client?

• How does not help?
• I have to do more for it to work
• I feel bad about myself
• I have to hide the scars
• It upsets my boyfriend

• How does it help?
• Makes me feel better
• Helps me feel in control
• Takes my mind off things

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Clients Self Injury Log

1. Time date of self injury
2. Situation or trigger
3. Thoughts feelings before self injury
4. Location/room where self injury took place
5. Wounds How many? Where on body? Use of tool?
6. Thoughts feelings after self injury
7. Reactions of others to the self injury

Enns, K. (2008). Self injury behaviour in
youth Issues and strategies. Winnipeg, MB
Crisis Trauma Resource Institute Inc.
26
Stopping Point

• When or how does client know to stop?
• Does client stop when they begin to feel pain?
• When does the client reach a stopping point?
• Visual aspect? Sensation of pain or numbing?

Wester, K. Trepal, H. (2005). Working with
clients who self injure Providing alternatives.
Journal of College Counseling, 8, 180-189.
27
Alternatives to Self Injury

• Relaxation training
• Containment strategies
• Mindfulness, emotional regulation distress
  tolerance skills (DBT)
• Physical activity/yoga/sports
• Communication with others
• Negative replacement behaviors

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Alternatives to Self Injury
Aggression/anger Tear up newspaper or phone book.
Throw ice cubes, rocks or eggs at a
wall. Punch a pillow. Restlessness Workout, go
for a run, walk or bike ride. Clean room.
Make noise. Emotional regulation Meditation,
belly breathing, repetitive counting,
writing Visuals Draw red lines on arms. Draw
slash marks on paper. Paint areas on
body. Sensations Snap rubber band on wrist. Ice
cube on skin. Clod shower.
Adapted from Wester, K. Trepal, H. (2005).
Working with clients who self injure Providing
alternatives. Journal of College Counseling, 8,
180-189.
29
Cycle of Self Injury
Trigger (Event or situation)
Reaction Anger, Shame
Automatic Thoughts
Feelings Fear, Anger, Sadness
Action Self Injury
-ve Self Talk
Twisted Thinking
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Cycle of Self Care
Trigger (Event or situation)
Reaction Relief That Lasts
Take a Breath (Slow Down)
Action Self Care (Without Injury)
What am I Feeling? (What Do I Need?)
ve Self Talk (I Can Handle This)
Am I Thinking Straight?
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Slowing Down the Process
The key to recovery is to slow down the process
so the client have time to consider what is
happening before they respond.
Trigger - Thought - Feeling - Self Talk - Action
Haswell, D., Graham, M. (2008). 5th Edition.
Overcoming self-abuse. Hamilton, ON S.A.F.E.
in Canada.
32
Trigger -Thought - Feeling - Self Talk - Action
What you do in response to an event or situation
is within your control depends on the following

• What you think about what is happening?
• Your emotions are at the time
• What you believe about yourself, others the
  world
• What you say to yourself about what is
  happening (Self Talk)

Haswell, D., Graham, M. (2008). 5th Edition.
Overcoming self-abuse. Hamilton, ON S.A.F.E.
in Canada.
33
Untwisting Your Thoughts
Ask yourself am I thinking straight?

1. Am I jumping to conclusions? Without enough
   information?
2. Am I assuming the worst? Catastrophizing?
3. Am I over generalizing? Always, Everyone, No
   body?
4. Am I caught in all or none thinking? Extremes?

Haswell, D., Graham, M. (2008). 5th Edition.
Overcoming self-abuse. Hamilton, ON S.A.F.E.
in Canada.
34
Changing Thought Patterns

• 1. Identify thought/belief about an
  event/situation that is leading to unpleasant
  emotions
• 2. Evaluate the accuracy of thought/belief
• Am I taking an extreme view?
• How else can I think about this event/situation?
• Am I only looking at the negatives ignoring
  the positives?

3. Stop the thought by taking a deep breath
replace the negative thought with a more helpful
thought
Enns, K. (2008). Self injury behaviour in
youth Issues and strategies. Winnipeg, MB
Crisis Trauma Resource Institute Inc.
35
Example
Start with an event Traffic jam Self Talk I am
going to be late. This is the third time this
week. My boss is going to fire me! (Hot headed
thoughts) Take a breath. Are my thoughts
helping? What is another way I can think about
this? (Cool headed thoughts) Alternative Self
Talk I dont want this to be a habit. Tomorrow
Ill give myself more time.

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Managing Relapses

• Changing thought patterns takes time and
  practice. Relapses or return to self-injuring
  patterns are often a part of the change process.
• If a relapse occurs ask
• What do I need to do to get back on track a
  bit?
• What has worked before?
• What have I learned that will help in the
  future?

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Self Care Without Self Injury UNB Counselling
servicesSix-2 hr Group Sessions Dr. Nancy
Buzzell Sarah Smith
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Pre-Group Interview

• Opportunity for prospective group members to
• Meet facilitators
• See the group room
• Ask questions
• Be supported in determining their readiness

39
Pre-Group Interview

1. Does person have the ability to function on a day
   to day basis? Ideally person should not be in
   personal crisis or in the midst of a major life
   transition
2. Does person have the ability to discuss her self
   injury issues without intense anxiety,
   dissociation or depressive reactions? When it
   began, what occurred, extent of current self
   injury
3. Does person have the ability to function in
   groups? Have they been in other groups? Does
   she have any concerns about being in a group?

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Suggested Questions

1. Introductions
2. Can you tell us about yourself? Year? Program?
   Living situation?
3. Can you tell us a bit about your self injury?
   How you are currently doing regarding self
   injury?
4. Is there anything you are currently doing that
   helps a bit?
5. What are your reasons for participating in the
   group?

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Suggested Questions
6. What do you want to get out of the group? 7.
Can you tell us about the support you have for
being in the group? Family? Friends? Health
care professionals? 8. Do you have any
questions or concerns? 9. Do you think you
would like to be in the group? 10. Can you
commit to all six group sessions?
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Group 1 Introduction Safety

• Introductions
• Group guidelines
• Goals for the group
• Why self injury works
• Harm Reduction Safety plan
• Belly breathing practice
• Check out
• Homework Case studies

43
Group Guidelines

• Attendance
• Listening all opinion accepted
• Confidentiality
• Self Responsibility Option to pass
• Commitment
• Other Scents, drinks/snacks

44
Group 2 Understanding Your Behaviour

• Check In Reaction to case studies
• History function of self injury
• Addiction model relapses
• Slowing down your cycle
• Progressive muscle relaxation
• Check out
• Homework Increasing your odds

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Group 3 Coping

• Check In Increasing your odds
• Regulation of impulses
• Fear of losing control
• Anxiety relief technique (5,4,3,2,1)
• Surviving the urge
• Place in nature visualization
• Check out
• Homework Coping Bank

46
Group 4 Managing Emotions

• Check In coping bank
• Understanding your emotions
• Emotional expression without self injury
• Social context of anger
• Anger management strategies
• Check out
• Homework Self help activities

47
Group 5 Facing Your Life

• Check In self help activities
• Self esteem 101
• Self esteem relationships
• Boundaries
• Leaf meditation
• Check out
• Homework Boundary awareness

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Group 6 Living in the Present

• Check In boundary awareness
• Your relationship with your body
• Dear body letter
• Plans to continue self care in the future
• The rest of your life
• Raisin meditation
• Check Out
• Circle of gifts

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Web Based Resources

• www.lifesigns.org.uk
• www.canadian-health-network.ca
• www.selfinjury.com
• www.safeincanada.org
• www.siari.co.uk
• www.youthnoise.com
• www.selfinjury.org.uk/index.html
• www.dailystrength.org
• www.recoveryourlife.com
• www.selfinjury.com/blog

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References
.
Adrian, M. (2010)  A cumulative risk model of
non-suicidal self-injury Contributions of
emotion regulation and contextual invalidation.
 Dissertation Abstracts International Section B
The Sciences and Engineering, 70,
44-72. Alderman, T. (1997). The scarred soul
Understanding ending self inflicted violence.
Oakland, CA New Harbinger Publishers. Gratz,
K., Chapman, A. (2009). Freedom from self
harm. Oakland, CA New Harbinger
Publishers. Haswell, D., Graham, M. (2006).
Overcoming self abuse. http//ca.geocities.com/sa
febc/new_page_11.htm. Heath, N. L., Ross, S.,
Toste, J. R., Charlebois, A. Nedecheva, T.
(2009). Retrospective analysis of social factors
and non suicidal self-injury among young adults.
Canadian Journal of Behavioral Science, 41,
180-186. Hoff, E. R. Muehlenkamp, J. J.
(2009). Nonsuicidal self-injury in college
students the role of perfectionism and
rumination.  Suicide and Life Threatening
Behaviour, 39, 576-587.
51
References
Hollander, M. (2008). Helping teens who cut.
NY Guilford Press. Mahadevan, S., Hawton, K.
Casey, D. (2010). Deliberate self-harm in
Oxford university students, 1993- 2005 A
descriptive and case-control study.  Social
Psychiatry and Psychiatric Epidemiology, 45,
211-219. ?Ross, S., Heath, N. L. Toste, J.
(2009).  Non-Suicidal self-injury and eating
pathology in high school students.  American
Journal of Orthopsychiatry, 79, 8392. Serras,
A., Saules, K., Cranford, J. A. Eisenberg, D.
(2010). Self-injury, substance use and
associated risk factors in a multi-campus
probability sample of students.  Psychology of
Addictive Behaviours, 24, 119-128. Simeon, D.,
Favazza, A. (2001). Self-Injurious behaviors
Phenomenology and assessment. In D. Simeon E.
Hollander (Eds.), Self-injurious behaviors
Assessment and treatment (pp.1-28). Washington,
DC American Psychological Association. Wester,
K. Trepal, H. (2005). Working with clients
who self injure Providing alternatives. Journal
of College Counseling, 8, 180-189.