Responding to Self-Injurious Students:
Prevention and Intervention Strategies
Richard Lieberman,
NCSP
Los Angeles Unified School District
School Mental Health
Suicide Prevention Services
[email protected]
Youth Suicide
NATIONAL TRENDS
 4320 youth aged 10-24 in 2007
 2659 20-24 (12.7)
 1481 15-19 (6.9)
 180 10-14 (0.9)
 3rd leading cause of death for youth age
10-24
 Most common method changed from guns
to suffocation among girls.
California
 3602 suicides in 2007 (34,598 US)
 #43 US rank (all ages):
 #47 US rank (15-24):
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

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
9.9 (11.5 US)
6.9 (9.8 US)
3rd leading cause of death 10-24
80% Males/20% Female
48% used firearms/24% suffocation (50%/24% US)
Females: 61% of attempts (overdoses 77%/cutting 15%)
Ethnicity:

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73%
15%
08%
04%
White
Black
Asian/American Indian combined
Hispanic (22% of attempts)
Los Angeles County:
2008 Suicide Data
 Total: 17 between 12-17 (11 males/6 female)
 7 LAUSD students
 6 under age 14
 Method
 12 Hanging (8 male/4 female)
 3 Firearm (all male)
 2 Jump from height (all female)
LA TRENDS in Youth Suicide:

1994-2003 ~26 annually

2004-2008 ~13 annually
 Cultural
 8 Hispanic/3 each White, African American, Asian
 Descriptive data
 12 experienced recent loss
 11 previous DCFS
 4 (showed warning signs; history of MI; previous attempts
and previous alcohol & substance abuse)
Youth Risk Behavior Surveillance Survey
Centers for Disease Control
LA
%
USA
%
Felt so sad or hopeless almost every
day for two weeks or more in a row
that they stopped doing some usual
activities.
30.1
26.1
Seriously considered attempting
suicide.
12.6
13.8
Made a plan about how they would
attempt suicide.
10.7
10.9
Actually attempted suicide.
8.8
6.3
Suicide attempt had to be treated by
doctor or nurse.
3.2
1.9
2009
Youth Risk Behavior Surveillance Survey
Centers for Disease Control
LA
2009
LA
2007
LA
2005
LA
2003
LA
2001
Percentage of students who felt so sad
or hopeless almost every day for 2 or
more weeks in a row that they
stopped doing some usual activities
30.5
-13.3%
31.5
32.6
34.6
35.3
Percentage of students who seriously
considered attempting suicide
12.6
-24.1%
13.4
16.4
16.0
16.6
Percentage of students who made a
plan about how they would attempt
suicide
10.7
-23.0%
11.5
13.0
14.6
13.9
Percentage of students who
attempted suicide one or more times
8.8
-28.5%
8.1
9.9
11.4
12.3
Percentage of students who made a
suicide attempt that resulted in an
injury, poisoning, or an overdose that
had to be treated by a doctor or
nurse
3.2
(36.4%)
2.3
(28.4)
2.6
3.0
3.7
Continuum of Self-destructive
Behavior
Stressors: Chronic
Mental Illness
Thoughts
Warning signs
Behaviors
•Self-injury
Stressors: Acute
Precipitating Events
•Alcohol/substance abuse
•Suicide attempts
High risk groups USA
 White males
 Black males (10-14)
 White females (10-14)
 Asian females (15-19)
 Hispanic youth
 Gay and lesbian youth
 Native American youth
Non-Suicidal Self-Injury (NSSI)
“Self injury is the result of a very
complex, opportune and clever
interaction between cognitive,
affective, behavioral,
environmental, biological and
psychological factors.”
Prevalence
 15-20% lifetime rates with onset in early
adolescence
 Higher rates in clinical settings
 Significant gender differences
 Elementary: 50-60% female
 Wider array of behaviors
 Secondary: 60-70% female
 75% choose cutting or burning
 Little variation across urban/rural settings
 Whites more likely than Black/Hispanic
 Higher rates among LGBTQ
Classifications
 Compulsive SI
 Eating disorders
 Trichotillomania
 OCD
 Impulsive SI
 Episodic
 Temporary respite from distressing
thoughts/emotions
 Repetitive
 Significant risk for BPD
 High incidence of adverse childhood experience and
complex trauma
Signs of Self-injury
 Frequent or unexplained bruises, scars, cuts,
or burns.
 Picking, poking, scratching, hair pulling, head
banging.
 Consistent, inappropriate use of clothing
designed to conceal wounds (often found on
the arms, thighs, abdomen)
 Secretive behaviors, spending unusual
amounts of time in the student bathroom or
isolated areas on campus.
 General signs of depression, social-emotional
isolation and disconnectedness
Signs of Self-injury
 Alcohol & substance abuse
 Possession of sharp implements (razor
blades, shards of glass, thumb tacks, clips)
 Evidence of self-injury in work samples,
journals, art projects
 Risk taking behaviors such as gun play,
reckless driving, sexual acting out, jumping
from high places or running into traffic.
Etiology of Self-injury
 Cognitive
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Irrational thoughts, beliefs, assumptions
Self-derogation
Self-blame
Self-punishment
 Affective
 Emotional dysregulation/tension
 Behavioral
 Antecedents
 External positive/negative reinforcement
Etiology of Self-injury
 Environmental
Invalidating environments
Childhood adversity: trauma
Maltreatment: complex trauma
Exposure through
siblings/peers/media
 Stressors
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Risk factors of Self-injury
 Situational crises
 Victimization/exposure to violence
 Loss (Death, divorce, transience,
romance, dignity)
 School crisis (disciplinary, academic)
 Family crisis (abuse, domestic
violence, running away, argument
with parents)
Etiology of Self-injury
 Biological
 Opioid system
 Controls pain, reward and addictive behaviors
 Can signal need for greater frequency/depth
 Internal positive/negative reinforcement
 Sexuality/Sexual identity
 Parental rejection
 Higher rates of depression, substance abuse,
exposure to violence
Etiology of Self-injury
 Psychological
 Borderline Personality Disorder
 Depression (Bipolar Disorder)
 Anxiety Disorder (Post traumatic stress
disorder)
 Dissociative Disorder
 Eating Disorders
Functions of Self-injury
 Internal contingencies
 Positive reinforcement: Creates a desirable
state
 Negative reinforcement: Release tension or
distract/remove from disturbing thoughts
 External or social contingencies
 Positive reinforcement: Provides attention from
others
 Negative reinforcement: Offers escape from
interpersonal tasks or demands
Functional Assessment of Self-injury
 Self-Report measures:
 Functional Assessment of Self-Mutilation (FASM; Lloyd,
Kelly & Hope, 1997 )
 Assesses frequency, severity and motivations of SI
 Recommended: brief (10 minutes), relevant to adolescents
and useful in both clinical & nonclinical settings
 Ottawa Self-Injury Inventory (OSI; Cloutier & Nixon, 2003)
 27-items covering cognitive, affective, behavioral, and
environmental aspects of SI
 Only measure to evaluate evolution of SI by exploring
whether motivations for continuing behavior differ from
those for first trying the behavior.
Cloutier, P. & Humphreys, L. (2008). Measurement of NSSI in Youth. In M.K. Nixon & N. Heath (Eds.),
Self injury in youth: The essential guide to assessment and intervention. New York, NY:
Routledge.
Phenomenology of Self injury
 Isolation
 Engage in SI in isolation
 Mask behaviors and injury with clothes
 Having friends that are not friends with each other
places at greater risk
 Contagion
 Teens at height of imitative behavior. “Rite” of
togetherness
 Exposure to SM and parasuicidal behavior raises risk in
youth
 May spread among peer groups, grade levels, clubs
Interventions
“There is no single, correct
therapeutic approach.
Prevention is key.”
Favazza
Responding to students who self-injure:
Suggestions for school mental health staff
 Dispel myths:
 SI is a complex bio-psychosocial
phenomenon separate and distinct from
suicide.
 Cognitive, affective, behavioral, biological,
psychological and environmental factors
combine to produce the behavior and must
be addressed to eliminate the behavior.
Responding to students who self-injure:
Suggestions for school mental health staff
 Assess for NSSI & suicide risk
 Warn and involve parents
 Utilize school/community resources. Tighten the circle
of care
 Limit contagion
 Do not discourage self harm
 Do not rush to “contract for safety” but identify
caring adults at school and appropriate replacement
skills.
 Do teach substitute behaviors that focus on
communication skill building (journaling), reduction
of tension (exercise) and limiting of isolation.
Responding to students who self-injure:
Suggestions for school mental health staff
 Limiting contagion
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Rites of Togetherness
Divide students and assess individually
Identify friends who engage in SI
Target classrooms, grade levels
Identify “alpha” students
 Female: Borderline personality disorder
 Male: Antisocial personality disorder
 Identify moderate risk students (students with
past behaviors) and target for follow up mental
health services
25
Responding to students who self injure:
Suggestions for school mental health staff
 Limiting contagion
 School mental health professionals should refrain
from running specific groups that focus on cutting
rather focusing on themes of empowerment,
exercise/tension relief and grief resolution.
 Health educators should reconsider the classroom
presentation of certain books, popular movies, and
music videos that glamorize such behaviors and
instead seek appropriate messages in the work of
popular artists.
 Monitor the internet chat and websites
 SI should not be discussed in detail in school
newspapers or other student venues. This can
serve as a “trigger” for individuals who SI.
Responding to students who self injure:
Suggestions for school mental health staff
 Limiting contagion
 Those who SI should be discouraged from
revealing their scars because of issues of
contagion. This should be discussed and explained
and enforced.
 Educators must refrain from school wide
communications in the form of general assemblies
or intercom announcements that address selfinjury.
 In general, designated person should be clear
with the student that although the fact of SI can
be shared, the details of what is done and how,
should not be shared as it can be detrimental to
the well being of the student’s friends.
Responding to students who self-injure
Tips for Educators: DO
 Connect with compassion, calm and caring.
 Understand that this is his/her way of coping
with pain.
 Refer and offer to go with the student to your
school counselor, psychologist, social worker or
nurse.
 Discover the student’s strengths
 Help to create circle of care at school.
Responding to students who self-injure
Tips for Educators: DON‘T
 Discourage self-injury, threaten hospitalization,
use punishment or negative consequences.
 Act shocked, overreact, say or do anything to
cause guilt or shame.
 Never publicly humiliate the student or talk
about their SI in front of class or peers.
 Agree to hold SI behavior confidential.
 Make deals in an effort to stop SI.
 Make promises you can’t keep.
29
Responding to students who self-injure
Tips for Parents: DO
 Accept your child even though you do not accept
his/her behavior.
 Let your child know you love him/her.
 Understand that this is your child’s way of coping.
 Make you home a safe place by removing anything
that could be used as a tool for self-injury.
 Encourage participation in extracurricular activities
and outreach in the community (e.g. volunteering
with animals, nursing homes, tutoring or
mentoring)
 Reach out to the school and tighten the circle of
care.
Responding to students who self-injure
Tips for Parents: DON‘T
 Discourage self-injury, threaten
hospitalization, use punishment or
negative consequences.
 Overreact, say or do anything to cause
guilt or shame and never publicly
humiliate your child.
 Forbid your child to see friends but
monitor who he/she does see. Contact
other parents.
 Overprotect or blame yourself for your
child’s behavior.
SUICIDE PREVENTION:
Depression Screening Programs
 Signs of Suicide (SOS) for Middle/High Schools
 www.mentalhealthscreening.org
 Teenscreen
 www.teenscreen.org
 Life Events Scale: Level of exposure to violence
 http://www.pluk.org/training/Stress_Management.pdf
 Beck’s Depression Inventory
 Hamilton Depression Rating Scale (HAM-D)
 Reynolds Adolescent Depression Scale Second
Edition (RADS-2)
 Pediatric Symptoms Checklist (Parents)
Assessment of Self-injury
 Brief screening measures:
 Self-Injury Inventory (SII; Zlotnick et al., 1996)
 Assesses frequency, duration and types of SI
 Two subscales: SI (impulsive self destructive acts) & SM
(direct acts of harm to one’s body)
 Self-Harm Inventory (SHI; Sansone, Weiderman &
Sansone, 1998)
 22-item self report measure to assess lifetime history
 May be used to screen for BPD
Cloutier, P. & Humphreys, L. (2008). Measurement of NSSI in Youth. In M.K. Nixon & N. Heath (Eds.),
Self injury in youth: The essential guide to assessment and intervention. New York, NY:
Routledge.
Assessment of Self-injury
 Brief screening measures (continued):
 Self-Harm Behavior Questionnaire (SHBQ; Gutierrez,
Osman, Barrios, & Kopper, 2001 )
 Four sections (SI, previous suicide attempts, previous
threats, previous thoughts); Yes/No format
 Cost effective: ease of questionnaire that yields rich detail
of a clinical interview to assess history and risk for suicide
 Deliberate Self Harm Inventory (DSHI; Gratz, 2001)
 5 minute-17 item behavior-based self report measure
evaluating the frequency, severity, duration and type of
SI.
 May be helpful for monitoring progress over time.
Cloutier, P. & Humphreys, L. (2008). Measurement of NSSI in Youth. In M.K. Nixon & N. Heath (Eds.),
Self injury in youth: The essential guide to assessment and intervention. New York, NY:
Routledge.
Responding to students who self-injure
COGNITIVE
 Much of how we FEEL is determined by how
we THINK.
 CBT: Connection between thoughts and
behaviors
 Facilitated by directing attention away from
environment (people, situations, events) and
towards thoughts
 Replace negative perceptions with focus on
positive qualities.
Responding to students who self-injure
COGNITIVE
 Challenge inaccurate beliefs
 Personalization: relating negative events to oneself
when there is no basis.
 Dichotomous Thinking: seeing things as black and
white, all or none. This is usually detected when a
person can generate only two choices in a situation.
 Selective Abstraction: focusing only on certain
aspects of a situation, usually the most negative.
 Magnification-Minimization: distorting the
importance of particular events.
Responding to students who self-injure
COGNITIVE
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Structured/directive to achieve rational thinking
Inductive method: Begins with observations
Establish goals
Homework (commitment)
 Journaling
 Self care
 Reading
 Re-framing
 Communication skill building
 Help seeking dialogue
 Drawing/collage work
Responding to students who self-injure
AFFECTIVE:
 Emotional Regulation:
Awareness & understanding of emotions
Acceptance of emotions
Ability to control impulsive behavior
Opposite Action: Shifting attention away from cues
or stimuli associated with problematic affective
responses and acting in a manner opposite to
strong negative affect (i.e. breathing)
 Ability to use situationally appropriate emotional
regulation strategies in order to achieve goals
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Responding to students who self-injure
AFFECTIVE:
 Emotional Regulation (continued):
 Grounding: Connection with the sensory
perceptions of the here and now (Name 5 things
you see/hear/feel exercise)
 Relaxation: Techniques or exercises designed to
induce physiological calming.
 Diaphragmatic breathing:
 Progressive muscle relaxation:
 Mental imagery/visualization techniques (The
Lemon Tree)
 Emotion identification and expression: Feelings
vocabulary; matching feelings to physiological
response
Responding to students who self-injure
AFFECTIVE:
Resources
 UCLA Mindful Awareness Research Center – download
meditation audio
http://marc.ucla.edu/
 See following website for examples of downloadable
relaxation tapes:
http://www.utexas.edu/student/cmhc/RelaxationTape/index.html
 The National Alliance of Multi-Ethnic Behavioral
Health Associations which notes effective evidencedbased practices for communities of color
www.nambha.org
Responding to students who self-injure
BEHAVIORAL:
 Get active: Exercise
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Martial Arts, Tai Chi
Cycle/handball/tennis/soccer
Pillow fight
Punching bag
Dance
Flatten cans for recycling
Practice affect regulation skills (e-mail reminders)
Eat/sleep right
Play or listen to music
Artistic expression
Utilize multiple diversion techniques
Responding to students who self-injure
BEHAVIORAL:
 Replacement behaviors
 Get sensory input---aromatherapy, lip balm or
lotions
 Suck on hot candy
 Scribble with red crayon on arm or paper
 Brush skin with toothbrush
 Tear/scribble paper
 Use play-dough
 Squeeze stress balls
 Take hot shower/cold bath
 Scratch clothes
Responding to students who self-injure
BEHAVIORAL:
 Negative replacement behaviors
 Rubber bands
 Substitute ice or magic marker for sharp
implement
 Temporary tattoos
 Holding books out at arms length
 Standing on tip toes
 Parent permission!
Responding to students who self-injure
ENVIRONMENTAL:
 Counseling can be effective when focusing on
reducing the environmental factors that trigger
SI.
 Interpersonal Effectiveness skill building
 Helping student understand what their needs are in
their relationships
 Helping student develop effective ways of dealing
with others in order to get their needs met in a
healthy way.
 Respecting the self and others, listening and
communicating effectively, being able to say no,
dealing with difficult people and repairing
relationships.
Responding to students who self-injure
ENVIRONMENTAL:
 Trigger log: Self assessment Sheet
 Was there a trigger for you? (Was there something that
upset you?)
 What were you thinking at the time? (What was going
through your head?)
 How upset were you? (Rate 1-5, Very to Not at all)
 What did you do? (How did you handle the situation?)
 How well do you think you handled yourself? (Rate 1-5,
Poorly to Great)
 What were the consequences?
 Would you do anything differently and if so, what would
you do?
Heath, N.L. & Nixon, M. K. (2008). Assessment of NSSI in Youth. In M.K. Nixon & N. Heath (Eds.),
Self injury in youth: The essential guide to assessment and intervention. New York, NY:
Routledge.
Responding to students who self-injure
ENVIRONMENTAL:
 Foster Connectedness
 Connect at school
 Identify circle of care
 Involvement at school
 Call a friend (communicating with others)
 Do something nice for someone
 Advocacy: Reaching out to others through
volunteerism
 Play with a pet
Responding to students who self-injure
BIOLOGICAL:
 Serotonin (SSRIs)
 Prozac, Paxil, Zoloft
 Preferred treatment for depression and
anxiety disorders.
 Best utilized when in combination with
Cognitive behavioral therapy
 FDA advisory
 TADS
Responding to students who self-injure
PSYCHOLOGICAL:
 Mindfulness cognitive therapy (or
mindfulness-based cognitive therapy,
MBCT)
 Cognitive Behavioral Therapy (CBT) which
focuses on changing our thoughts in order to
change our behaviors
 Mindfulness, a meditative process of
identifying our thoughts on a moment-tomoment basis while trying not to pass
judgment on them.
Responding to students who self-injure
PSYCHOLOGICAL
 Dialectical Behavior Therapy (DBT)
 Pioneered by Marsha Linehan in work with
Borderline personality disorder
 Combination of individual, group and skills
training
 Hierarchical structure of treatment goals
 Success in reducing parasuicidal, SM behaviors
as well as reducing behaviors that interfere
with therapy
http://www.dbtselfhelp.com/index.html
Responding to students who self-injure
PSYCHOLOGICAL
 Dialectical Behavior Therapy (DBT)
 Decrease life-threatening behaviors (i.e., suicidal and
parasuicidal behaviors);
 Decrease therapy-interfering behaviors by client and
therapist that compromise treatment effectiveness
(e.g., nonattendance to treatment, arriving to session
in an intoxicated state, arriving late or leaving early,
falling asleep during session)
 Decrease quality-of-life interfering behaviors (e.g.,
substance abuse, bulimia, homelessness,
unemployment);
 Increase coping skills.
http://www.dbtselfhelp.com/index.html
Responding to students who self-injure
PSYCHOLOGICAL:
 “Mindfulness” skills
 Awareness and insight to differentiate between
emotional, reasonable and wise mind (e.g., don’t judge,
observe, describe, be in the moment, participate, do
what works)
 “Emotion Regulation” skills
 Mindfully observe and describe emotions, increase
experience of positive emotions
 Reduce vulnerability to intense, negative emotions
(e.g., improve physical health, sleep, diet, exercise,
avoid drugs, build mastery)
http://www.dbtselfhelp.com/index.html
Responding to students who self-injure
PSYCHOLOGICAL:
 “Distress Tolerance” skills
 Crisis survival strategies
 Emotional containment through distraction techniques
(i.e., self soothing, breathing, relaxation)
 Acceptance skill building
 “Interpersonal Effectiveness” skills
 Improving relationships and social supports
 Effective communication skills (e.g., be gentle, act
interested, be fair, be truthful, describe the issue,
express, assert, reinforce, confidence, negotiate, stay
mindful)
http://www.dbtselfhelp.com/index.html
Responding to students who self-injure
PSYCHOLOGICAL:
 Cognitive Behavioral Intervention for Trauma in
Schools (CBITS)
 Skills-based, structured group intervention aimed to
relieve symptoms of PTSD, depression and anxiety
among children exposed to trauma.
 Education about reactions to trauma
 Relaxation training
 Cognitive therapy
 Real life exposure
 Stress or trauma exposure
 Social problem-solving
Responding to self injury in the schools:
References
Lieberman, R., Toste, J.R., & Heath, N.L. (2008). Prevention and intervention in the
schools. In M.K. Nixon & N. Heath (Eds.), Self injury in youth: The essential
guide to assessment and intervention. New York, NY: Routledge.
Lieberman, R. & Susan, M. (in press) Self-injury: Information and guidance for
school personnel. In A. Canter, L.Paige, M. Roth, I., Romero, & S. A. Carroll
(Eds.). Helping children at home and school III: Handouts for families and
educators. Bethesda, MD: National Association of School Psychologists.
Lieberman, R., Poland, S. & Cassel, R. (2008). Suicide intervention. In Thomas, A. &
Grimes, J., Best practices in school psychology V. Bethesda, MD: National
Association of School Psychologists.
Lieberman, R. & Poland, S. (2006). Self-mutilation. In G. Bear & K. Minke, Children’s
needs III. Bethesda, MD: National Association of School Psychologists.
Walsh, B. W. (2006). Treating self-injury: A practical guide. New York: Guilford Press.
Lieberman, R. (2004). Understanding and responding to students who self-mutilate.
National Association of Secondary School Principals: Principal Leadership 4(7)
10-13.
Responding to self injury in the schools:
Assessment References
Self-Injury Inventory
Contact: Caron Zlotnick, Ph.D. Brown Medical School
[email protected]
Self-Harm Inventory
Contact: Randy Sansone, M.D. Sycamore Primary Care Center (Ohio)
[email protected]
Self-Harm Behavior Questionnaire
Contact: Peter M. Gutierrez, Ph.D. VA Eastern Colorado Health Care System
[email protected]
Deliberate Self Harm Inventory
Contact: Kim L. Gratz, Ph.D. Center for Addictions, Personality & Emotion
[email protected] or www.addiction.umd.edu
Functional Assessment of Self-Mutilation
Contact: Elizabeth Lloyd-Richardson Ph.D. Brown Medical School
[email protected]
Ottawa Self-Injury Inventory
Contact: Mary Nixon, M.D. Centre for Youth & Society
[email protected]
Responding to self injury in the schools:
References
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The Scarred Soul by Tracy Alderman
A Bright Red Scream by Marilee Strong
www.selfinjury.com
www.self-injury.net
www.selfharm.org
www.gaspinfo.com
 800.DONTCUT