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Self Harm

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Courtney rIsch

on 18 November 2014

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Transcript of Self Harm

Thank You!
Self harm in the forms of cutting, scratching, and pinching in both genders for adolescents and young adults ages 14-24.
Eating Disorders
Compulsive Disorders
Reactive Attachment Disorder
Three riteria of Boarerline Personality Disorder
Mood Disorders
Sustance Abuse
Trauma History (Abuse)
Maladaptive Attachmet Pattern
Dissociate Disorders
Family History
LGBTQ (3X's higher)
Ethical Issues
The Social Worker should have an understanding of social diversity and being culturally competent. They should have an understanding of their clients culture before making assumptions about treatment.

The Social Worker should also use competency to watch out for any escalation from self harm into suicidal ideation or thoughts.
Hard to determine since it often goes under reported
Affects of Self-harm
Anna Harris, Kristie Riojas, Courtney Risch, and Vanessa Sircy
Non-suicidal Self Injury
Evidence Based Research
Self-Care Issues
Sofi is a 14 year-old girl and is an only child. Recently her mother noticed that she was limping and asked to see her foot. When Sofi reluctantly took off her shoe her mother noticed she had a terrible cut on the bottom of her foot that was infected. When she was taken to the ER her mother noticed many thin scars on her forearms. Like most girls her age, her adolescence has been a time for many changes. She reports an increase in pressure to fit in. Furthermore, her parents have recently decided to get divorced and are struggling trying to co-parent. She is currently getting accustomed to the new custody agreement.

Her mother tells the hospital social worker of her discovery. The social worker arranges to speak with Sofi privately with consent from her mother.
More commonly found in females - 60 percent of those who self-injure are female.
Somewhere between 7-8 % of adolescents have self harmed at least once
Risk factor for repetition is high
More than 5% of people who have been seen at a hospital after self-harm will have committed suicide within 9 year -- Not a suicidal behavior!
33% of people who reported self-injury in two college studies said that they had hurt themselves so badly that they should have been seen by a medical professional; only 6.5% had ever been treated for any of their wounds.
A groundbreaking 2006 study conducted by researchers at Princeton and Cornell found that 17 percent of college students self-injure—cut, carve, burn, or otherwise hurt themselves.
"Self-harm refers to hurting oneself to relieve emotional pain or distress. The most common forms of this behavior are cutting and burning. The least common forms of self-harm include pulling out bodily hairs, punching walls, and ingesting toxic substances or sharp objects."
Few large scale treatment studies include self-injuring or suicidal individuals because of legal and ethical risks
Treatments utilizing a cognitive-behavioral approach show the greatest success in reducing NSSI behaviors
Short term vs. long term treatment
Short term, crisis intervention: Solution-focused
Long term intervention: Dialectical Behavioral Therapy (DBT-A)
DBT is an approach that depends on practitioner availability outside of consultation hours (via phone conversations between meetings)
Balancing professional boundaries is a challenging issue practitioners working with this population frequently experience

Plan for safety
Logging behavior
Diversion techniques
Negative replacement behavior
Physical exercise
Mindful breathing skills
Visualization techniques
Artistic expression
Cognitive restructuring
Family therapy
Issue of Confidentiality with parents
Nasw code of ethics on confidentially:
Please feel free to consult your colleagues in the NASW Ethics Hotline, at (617) 227-9635. Leave your name and phone numbers where you can be reached with the operator. Your call will be returned within 24 hours by a member of the Committee.
1.07 Privacy and Confidentiality

(a) Social workers should
respect clients’ right to privacy.
Social workers should not solicit private information from clients unless it is essential to providing services or conducting social work evaluation or research. Once private information is shared, standards of confidentiality apply.

(b) Social workers
may disclose confidential information when appropriate with valid consent
from a client or a person legally authorized to consent on behalf of a client.

(c) Social workers should
protect the confidentiality of all information obtained in the course of professional service,

except for compelling professional reasons. The general expectation that social workers will keep information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and imminent harm to a client or other identifiable person. In all instances, social workers should disclose the least amount of confidential information necessary to achieve the desired purpose; only information that is directly relevant to the purpose for which the disclosure is made should be revealed.

ocial workers should inform clients, to the extent possible, about the disclosure of confidential information
and the potential consequences, when feasible before the disclosure is made. This applies whether social workers disclose confidential information on the basis of a legal requirement or client consent.

(e) Social workers
should discuss with clients and other interested parties the nature of confidentiality and limitations of clients’ right to confidentiality.
Social workers should review with clients circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. This discussion should occur as soon as possible in the social worker-client relationship and as needed throughout the course of the relationship.

(f) When social workers provide counseling services to families, couples, or groups, social workers should seek agreement among the parties involved concerning each individual’s right to confidentiality and obligation to preserve the confidentiality of information shared by others. Social workers should inform participants in family, couples, or group counseling that social workers cannot guarantee that all participants will honor such agreements.

(g) Social worker
s should inform clients involved in family, couples, marital, or group counseling of the social worker’s, employer’s, and agency’s policy concerning the social worker’s disclosure of confidential information among the parties involved in the counseling.

(h) Social workers should not disclose confidential information to third-party payers unless clients have authorized such disclosure.
Other ideas to use when a parent is insisting you break confidentiality include:
• Using
empathic listening
with the parents and allowing parents to vent

Developing rapport
and validating feelings
• Using professional judgment as to what constitutes the
“appropriate” inclusion
of parent and documenting the reasoning

Asking student’s permission
to share

Reframing confidentiality as an important developmental step toward independent thinking
• Explaining that if the client does not trust the social workers commitment to confidentiality, the child may not share honestly

Explaining the ethical codes
to parents

Suggesting parents themselves ask the child
about the desired information

Discussing different approaches
parents might employ with their children

Suggesting parents and child meet together with social worker

Informing the clients of their parents’ inquiry
and suggesting ways to talk to parents
• Consulting with a colleague
When considering breaking confidentiality, there are a number of other considerations and suggestions to take into account:
• Consider the child’s relationship with the parents.
• Consider child’s relationship with you.
• Prepare the student to take the lead in sharing information with parents.
• Ascertain child’s role his or her family.
• Consider cultural differences.
• Practice within the limits of your abilities.
• Ask the minor to provide permission to break confidentiality in writing.
• Keep accurate and objective records of all interactions.
• Recognize how your own values and beliefs may influence how dangerous you perceive students’ behaviors to be.
• Maintain adequate professional liability coverage.
• Establish a network of peers to consult, both in and out of school.
• Engage in professional development regarding ethical issues.
• Request periodic in-services on policies regarding confidentiality.
• Educate stakeholders concerning the rationale of confidentiality.
• Ensure periodic updates of state laws and district policy.
• Establish in advance behaviors that might warrant breach of confidentiality.
Case for the class:
There are many assessment for NSSI - So Choose wisely!!!!!
Assessments will highlight different characteristics of the behavior
Some have been designed for specific populations
Assessments will help determine which interventions are best for that specific client
Listed in
Self-Injury in Youth: The Essential Guide to Assessment and Intervention
9 self-report measures
2 structured interviews
The Functional Assessment of Self-Mutilation (FASM)
Developed for adolescents and commonly used with them
Self-injurious behavior measured: Self-harm (with or without suicidal intent)
Assess for self-destructive and impulsive acts
Characteristics of self-injury: Frequency, durations, types
Goes a step further as assesses function
Deliberate Self-Harm Inventory (DSHM)
Not developed for adolescents but can be used with them.
Self-injurious behavior measured: NSSI
Characteristics of self-injury: Frequency, severity, type, duration
Self-Harm Inventory (SHI)
Not used or developed for adolescents
Self-injurious behaviors measured: suicidal behavior, direct and indirect self-harming behavior
Characteristics of self-injury: total number of self-injurious behaviors in clients history
Ottawa Self-Injury Inventory (OSII)
Characteristic of self-injury: Methods, frequency, reasons, context, adaptive properties, effectiveness of behavior at regulating negative affect, motivation for change
Tracks NSSI over a period of time
This assessment is useful because correlations can be made for why the behavior started and why it continues to occur.
Designed and used for adolescents
Self-injurious behavior measured: NSSI, suicidal ideation, and suicide attempts

Cognitive Behavioral Theory

"Emotional and behavioral disturbances do not arise directly in response to an experience but from the activation of maladaptive beliefs in response to an experience."
The Social Workers Desk Reference
, pg. 242
CBT focuses on three areas:
Content or thoughts
Core beliefs
Dysfunctional processing or cognitive misrepresentations
Crisis: Solution Focused Therapy
Long-term: DBT-A
Warning Signs!

Unexplained frequent injury including cuts and burns.
Wearing long sleeves and pants in warm weather.
Low self-esteem.
Difficulty handling feelings.
Relationship problems.
Poor functioning at work, school or home.
The appearance of lighters, razors, or sharp objects that one would not expect to find among someone's belongings.
Notoriously hard to detect. Not a lot of data because people are not willing to self-desclose.
Listen for
Feelings of emptiness
Over or under stimulated
Not understood by others
Fearful of intimate relationships and adult responsibilities
Dialectical Behavioral Therapy
Dialectical Behavioral Therapy is an adaptation of traditional Cognitive Behavioral Therapy originally developed by Dr. Marsha Lineham to treat women diagnosed with Borderline Personality Disorder
Since its inception, DBT has shown higher efficacy rates in treating a myriad of mental health issues compared to treatment as usual (TAU)
Evidence gathered from research suggests that DBT is a promising treatment for adolescents in a variety of settings with a range of psychological and mental health issues including suicide, affective disorders, substance use, personality disorders, eating disorders and self-injury
DBT focuses on strengthening skills in four realms
Distress Tolerance: cope with painful events
Mindfulness: experience the present moment
Emotional Regulation: recognize feelings
Interpersonal Effectiveness: set limits and negotiate solutions
Adolescents are more likely to complete treatment,have fewer hospitalizations and have a more significant reduction in symptoms (including NSSI) when receiving DBT treatment versus TAU
DBT-A is a modification of traditional DBT and is used exclusively with adolescent patients
DBT-A is similar to traditional DBT but additionally incorporates family therapy into the treatment plan
Two components of DBT
Individual Counseling
Clinician works with adolescent on specific issues, developing new coping skills and monitoring progress
Group Skills sessions
Weekly sessions lasting between 2-3 hours
Patients work through the four modules and practice skills related to mindfulness and identifying triggers
Clinician must be available iin the event of an emergency for patients receiving intensive DBT
Growing up I didn’t have the worst childhood but it was still rough. I have been through some stuff with family members. I was teased in school a lot, especially when I had to move states in the middle of a school year. That's when it all started. My parents found out about a year after I started and said that I was just attention seekin and I would grow out of it. They said it was just a teenage phase.

Friends who have knowledge of my self-harm think I might be crazy. I'm not friends with those people anymore. They couldn't handle my "manipulative" behavior. Some people are convinced I will kill myself and others even think that I have tried. I don't know why. The marks are not that bad so I don't understand why they would think I have a serious problem.

I stopped for a while and only recently started again. Why? Mainly stress and not living up to expectations of others. Something I struggle on a day to day basis to be okay with who I am. Although I can easily see the beauty and strength in others I can’t see it in myself. I guess
there is nothing that can help me.
Solution Focused Therapy
Short-term approach to intervention that focuses almost exclusively on developing solutions and identifying exceptions to problems
Problems can be resolved without understanding causes
Problems result from cycles of behavior that have been reinforced
Rigid beliefs and attitudes prevent people from noticing new information
Views change as constant and occurring by reinterpreting situations and filling information gaps
Views change as behavioral or perceptual
Small change can snowball; thus rapid change is possible
Future oriented
Goals of Intervention

Focus on solutions to problems
Help clients to act or think differently than they usually do
Highlight client strengths and resources
Recognize when a problem is not occurring
Intervention Techniques
Normalize problems
Compliment to focus on positives
Offer alternative perspectives on typical patterns of thinking, feeling and behaving
Externalize the problem (reframe)
Scaling questions
Exception seeking questions
Coping questions
The Miracle Question
Problem free talk
Suggest easier alternatives to prior solution attempts
Cultural Issues
Who Is at Risk?
Who this affects
Cultural Issues
Ethical issues
At risk
Some female African tribes use facial scaring for decorative factors.
The Bible contains many references to self mutilation behaviors

Ex:Mark's Gospel "If it causes you to sin, cut it off...and if your eyes causes you to sin, pluck it out".

Many cultures use body piercings, tattoos, and scaring as cultural identification.
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