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Topic: Self-Mutilation Behavior in Youth and Adults

Place: Affinia Hotel, Manhattan, NY

Date: Thursday, June 22, 2006

Time: 7:30am – 3:30pm

Presented by: Joseph Shannon, PhD

By Gabriel Rueda – Intern PCCF (Pastoral Counseling Center of Flushing)

About the Seminar

I believe that this seminar was one the best investments ever made by organizations that direct or sponsor mental helpers. As an intern, I believe that the Pastoral Counseling Center of Flushing made a great investment and those who suffer from this mental disorder will greatly benefit with the use of this material.

What is Self-Mutilation?

Self-Mutilation is the intentional act of destruction of tissue damage to one’s body. It is also known by other names such as self-injury, self-harm, and self-abuse.

The Myths/Misunderstandings of Self-Mutilation

1. Self-mutilation rarely represents a suicidal gesture. It is generally not an intention to commit suicide since this is viewed by many individuals who self-mutilate as an act of suicide prevention. Only 2% or less of this population represents suicide.
2. It is, generally speaking, not an attention-seeking behavior. It can be a type of attention-seeking behavior, but only less than 2% of this population does it for this very reason. Reality is that the vast majority of self-mutilators are ashamed or embarrassed and they go to great extremes to hide their behavior.

Types of Self-Mutilation that Exist Today:

The most commonly seen behaviors of this self-inflicted violence are:

• Cutting – shallow cuts to skin of arms/legs or parts of the body such as breasts, face and genitals.
• Burning – in fingers, arms, inner thighs
• Head-banging – hitting the head against a wall or other hard surfaces.
• Bruising – anywhere in the body.
  
  

It can also include excessive body piercing, tattoos, hair pulling, marking, scratching, biting, carving, picking/pulling skin; or can include more serious flesh wounds, fracturing bones, or even removal of limbs through medical operation.

What are the reasons for Self-Mutilation? Why do People do this?

• Adolescents and adults who have difficulties verbally expressing their feelings can release their emotional tension, pain and low self-esteem by self-mutilation methods. In a way self-mutilation is “the voice of the skin and bones”.
• It is the means by which adolescents and adults distance themselves from emotional pain and it is a physical release of all the accumulated anger, stress, traumatic experiences (e.g. sexual abuse) or unresolved emotional problems.
• Feelings of emptiness, boredom and numbness. When people self-mutilate the beta-endorphins in the brain are released and a feeling of well-being is produced.
• Peer pressure. It may be the means by which a person can be accepted in a group.
• Social isolation or alienation from peer group.
• Dysfunctional family dynamics. Boundary violations (e.g. sexual abuse), triangulation (when parents use kids and pump information from them), enmeshment/disengagement, substance abuse, psychopathology in parents.
• Self-Mutilation can be a symptom of a more serious illness such as PTSD, major mood disorders (e.g. major depression, bipolar I or II), eating disorders (e.g. bulimia), schizophrenia, borderline personality disorder, anxiety disorders (e.g. OCD).

What is the Target Population?

It has been estimated that 3 million people in the US self-mutilate. That is approximately 1% of the population, with higher incidents in adolescents.

Most sufferers of self-mutilation are women (2:1) ratio.

Incidents in women are more linked to sexual abuse, and in men to physical abuse.

The average person that starts harming himself/herself starts at age 14 and continues into late 20’s.

How Can Self-Mutilation Be Treated and Prevented? What Can Be Done?

There are (1) Validation Strategies and (2) Skills Training Strategies.

1. Validation Strategies include:
   Emotional Validation – provide an environment/opportunity for the patient’s emotional expression, teaching patient how to observe and name feelings, and communicating to patient that his/her feelings are valid.
   
   Behavioral Validation – Teaching the patient to observe and describe his/her behaviors, accepting patient’s behavior in a non-judgmental way, and validating patient’s disappointments for his/her own behaviors.
   
   Cognitive Validation – Teaching the patient to observe and describe his/her own thought process and interpretations, respecting patient’s opinions and values, and accepting/supporting patient’s growing ability to balance the rational with the emotional.
   
   Supportive Strategies – Encouragement, praise, re-assurance, focus on capabilities, and availability for assistance when patient is in trouble.
   
   
2. Skills Training Strategies include:
   Core Mindfulness Skills – Balancing reason and emotion when facing stressful challenges.
   
   Distress Tolerance Skills – Coping with stressful life events. It includes crisis survival and acceptance skills.
   
   Interpersonal Effectiveness Skills – Many of those who self-mutilate lack certain interpersonal skills for coping with conflicts.
   
   Emotion Regulation Skills – identify/label emotions, identify obstacles to change emotions, reducing negative emotions, increasing positive emotions, acting in ways that are opposite of current emotions, and applying distress tolerance techniques (e.g. imagery, meaning/finding purpose, prayer, relaxation, vacation, and encouragement).

Other Techniques That Can Be Used For Treatment:

• Rubber Band Technique – 10 times a day max
• Take uncomfortable hot bath – No more than 2 minutes.
• Take a cold shower – No more than 15 minutes.
• Grab ice cube until it melts or until hand completely numbs
• Teach client benign things to distract the pain, things that they can do that will not make them feel guilt or emotional pain (e.g. exercise, cleaning, meditation, art)
• Run a list of things that can give the client a sense of pleasure (e.g. reading a good book) and mastery (e.g. refinishing furniture).
• Egg timer technique – cognitive behavioral technique. (1) Instruct patient to set timer for 45 minutes; they are to make a list of all awful/terrible things that have been a source of pain, and let themselves feel the pain. (2) Instruct patient to set timer for 15 minutes and have him/her make a gratitude list and positive things in his/her life.
• Psychodynamic Technique – phonebook technique. Ask patient to think of source of pain; what does he/she relate it to? Have client identify specific issue of resentment, rip off a page of the phonebook and imagine that the page is a physical representation of the pain, wad it up into a ball and simultaneously have the client throw it against the wall as he/she yell out his/her resentment (e.g. “ I resent that I’m disable”). Give client a bag and have him/her put all wadded paper in it, and finally go with him/her to dumpster to throw it out.
• Family Sculpt Technique – a cathartic (emotional release) experience. Based on a genogram, family members (generally a group of 8-10 family members) and two facilitators (ideally one male and one female) create a physical scene that represents the nature of their relational positions and proximity in the family. The client, for example, describes to the group what the pain is, and how he/she has been affected. Sculpting frequently helps to get the client and his family loosened up, as attitudes and distances become visual, and core beliefs/ feelings are identified and brought forth into the counseling room.
• When self-mutilation is a symptom of a more serious illness, other techniques are used. For example, in cases of PTSD, the patient can be taught grounding techniques which are techniques that use the five senses to prevent disassociation (e.g. doodling, wise/mind breathing technique); psychotherapy (it focuses on the conscious thoughts and feelings of trauma, what client is aware of); targeted pharmacotherapy (to get patient to normal level life); and Neurofeedback therapy (deals with the part of trauma that client does not remember). One of the techniques used to help the client remember is EMDR (Eye Movement Desensitization and Reprocessing) technique. With this technique the person remembers the trauma, the neuro-chemical levels and brain functioning changes and re-adjusts; and it allows the individual to re-integrate, to recall the trauma, and bring the brain to normal functioning. This technique increases and stimulates the electrical activity in the brain and makes both sides of the brain work at the same time.

What Can Parents Do?

• Inform themselves about self-mutilating disorder
• If parents suspect self-mutilation, they should look for factors such as: teens wearing long-sleeve shirts and pants constantly even in the summer, observe unexplainable wounds (e.g. multiple scratches that keep appearing), teen’s inability to express his/her feelings.
• Listen and not ignore what the child is saying about doing harm to himself/herself.
• Talk to the children about the topic and about the importance and value of the body.
• Remember that ultimatums do not produce any good results
• Listen and speak openly about self-mutilation conduct
• Help their children develop social skills, so they can talk about their feelings and solve problems.
• Help them obtain the assistance of a professional mental helper if necessary.

What Can a Teen Do?

• Identify his/her feelings instead of acting upon them.
• Determine what impulse is behind the act of self-mutilation (e.g. feeling pain, seeing blood, seeing scars, relief from depression, anger).
• Don’t be afraid to talk to his/her parents.
• Call a friend and talk about it.
• Write a journal.
• Physical and breathing exercise
• Meditation
• Art
• Volunteer work
• Cleaning
• Videogames