welcome, while we wait for others to join: 1. click on the telephone icon in the app 2. click on...
Post on 14-Dec-2015
216 Views
Preview:
TRANSCRIPT
Welcome,While we wait for others to join: 1. Click on the telephone icon in the app 2. Click on "Call via internet" 3. Click on "Connect" 4. Adjust your volume
Welfare Guardian
Responding to Self-harm in Schools
Dr Erin BoweClinical Psychologist
Welfare Guardian
Current and preferred term is ‘nonsuicidal self-injury’ (NSSI)
‘self-harm’ or ‘self-injury’ is easier for everyday speak
Regional differences in terms Self-poisoning has different motivations & lethality
Nomenclature
To better equip yourself and staff to deal with common incidents
To improve skills in determining appropriate level of response for a range of possible crisis events
To learn tricks in using principles of calm, factual and non-emotive language
To have a clearer understanding of how to seek further advice and support for yourself, staff, students and parents
Introduction: Goals of session
Understanding self-harm behaviours Responding to crisis Communication skills Special considerations within school
settings Self-care, supervision and referral
Overview
Pre and post-workshop reflection
0= NOT AT ALL CONFIDENT 1= SOMEWHAT CONFIDENT 2= CONFIDENT
How confident do you feel: Working with students who have engaged in self-harm? Being able to differentiate a crisis from more intermediate
and mild incidents? Understanding best-practice treatment approaches for self-
harm? That you could handle a crisis?
Deliberate cutting, burning, scratching with the intent of causing bodily tissue
For the purpose of affect regulation (to feel ‘better’, ‘calmer’ or just ‘different’)
Almost always non-suicidal Usually repetitious Usually associated with powerful, rewarding
psychophysiological responses A maladaptive, but effective coping strategy
Self-harm is
A suicide attempt Parasuicide (behaviour which mimics suicide attempt) (Sub)culturally accepted body modification Stereotypic/compulsive self-harm (neurological basis) Psychotic self-harm (e.g., self-amputations) Indirect or cumulative bodily damage (eating disorder,
substance use, or risky stunts)
Self-harm in this context is not to be confused with:
Predisposing factors
Stressful events Self-harm specific factors
Self-harm outcome=+x
Cognitive-emotional-biological vulnerability
• High emotion reactivity
• Emotional numbing
• Poor distress tolerance
• Thought suppression
• Rumination
Social vulnerability
• Early abuse/maltreatment
• Familial hostility/criticism
• Poor communication skills
• Poor problem solving
• Stressful event
Triggers over or under
Arousal (automatic
Functions) OR
• Event presents high
Social demands
(Social function)
Self-harm
• High self-criticism
• Modelling of peers/media
• Need for strong/honest signal
Regulation of emotional experience
Regulation of social situation
Psychological model of the development and maintenance of self-harm (Nock & Cha, 2009)
Appears to be 3 possible pathways
1. ‘One-off’, non-rewarding response (about 30%)2. Tension reduction* response (about 70% will repeat)3. Atypical, excitation** response (seen in Borderline PD; or
a least a subtype of BPD, unknown % but likely very low)
*Well established in literature**Less well established in literature, still speculative
Who does it?
Increased levels of negative emotions
Depersonalisation occurs
Individual reaches a level they are no longer able to tolerate
Engage in act of self-harm with little/no pain (injury opens access to the brain’s 24 hour pharmacy of endorphins &
opiates)
Repersonalisation occurs (negative reinforcing property)
‘Typical’ response: tension reduction model
Poor coping skills Low tolerance for negative emotions Impulsive, want instant relief Perceived lack of control High levels of dissociation Often unable to utilise problem solving once
distress reaches a certain threshold
Typical response
Experience interpersonal conflict, rejection, separation, anger, self-hatred, depression, loneliness and abandonment
Experiences may be real or imagined As self-harm become habitual, cutting is
often precipitated by more minor events
Typical response
Most people have a hard time explaining “why” they cut (content)
But can describe what, where, how led to the behaviour (process)
Does the “why?” change anything? Fundamentally, self-harm is a maladaptive coping
strategy It’s an attempt to communicate distress Counsellors should try to prioritize process over
content
Faulty Assumptions- “why?”
You or another student finds someone cutting in private (e.g., in bathroom)
1. Respond neutrally & model calm posture (think: relax jaw, relax hands, relax shoulders)
2. Offer support (get band aids, offer a chance to talk about it) without being reactive
3. Use empathic statements, focus on immediacy
Crisis #1
4. Immediacy- ask the student what s/he wants to happen next an offer 2-3 options.5. Follow up. Book a time to talk, or talk to the student about referral. 6. Reflect on your own self-care & debriefing needs
Crisis #1 continued
A student or students engage in self-harm in front of others (e.g., in class)
1. Use empathic reminders that (1) it’s ok to be upset, but (2) others are upset by the behaviour.
2. Offer support (bandaids, a chat)3. Offer 2-3 options: 1. clean up & go back to
class, 2. Sit somewhere quiet with a friend until next class, or 3. visit counsellor/debrief with someone
Crisis #2
4. Manage any other students’ distress by acknowledging & validating, but quickly moving forward (give the same options – break, talk, or resume class)5. Follow up. Book a time to talk, or talk to the student about referral. 6. Reflect on your own self-care & debriefing needs.
Crisis #2 continued
A student reveals that s/he has engaged in self-harm (but no current crisis)
1. Simply ask the student what s/he wants to have happen now (talk now, or later?)
2. Make sure a follow up time is booked (preferably by the end of the day)
3. Aim to clarify the intent (“so the cutting was about feeling overwhelmed, but not about taking your life?”)
Non-immediate crisis
4. Encourage parental communication (consider age and mature minor principle if necessary)5. Encourage a referral to an external psychologist (particularly important if the student is not open to parental disclosure)
Non-immediate crisis cont.
No, not unless absolutely necessary Tends to reinforce the behaviour Increases feelings of rejection & isolation
Send students home?
Represents a unique but not unusual occurrence in ‘institutional’ settings (schools, hospitals, prisons)
Contagion effect Important to correct any misinformation and
address ‘us vs. them’ phenomena Work towards strengthening alliance
between parents, adolescents and counsellor
Self-harm in groups & cliques
Can be effective if student has a circle of non self-harming friends
Similarly, older students who have recovered are a strong source of modelling and support
Groups with only people who self-harm need to be selected very carefully, they need to be highly structured and run by an experienced therapist
Addressing the Issue: Groups?
False assumption that all members want to change; or that the motivation for change is stable/consistent
Participant matching issues in school setting Members can often provide false validation rather than
support Extra challenges with personality disorder, trauma, eating
disorder and substance use Risk of re-triggering & re-traumatisation Risk of ‘one-upmanship’ behaviours Biased motivations for participating ‘sharing’ not as effective as structured skill-based groups
Risks with Groups
Immediacy Neutral tone of voice, face and statements Importance of orienting the student to counselling process Try to avoid the temptation to get into lengthy discussions
with students or parents about “why” people self-harm Teach/model skills in emotion identification, labelling and
explaining Focus on the factual information about the mechanics or
the process (i.e., reduces heart rate, body releases natural feel-good opioid hormones)
Communication skills
Crisis management, putting out ‘spot fires’ Educating others, translating knowledge Explain behaviour curve- delay, distract, decide Ongoing motivational interviewing Encourage replacement skills early on, but
acknowledge their limited use & use as a tool for encouraging long-term strategies
Realistic options for school counselling
Anxiety is the biggest block to care Listening your own thoughts, rather than the
students Can’t be present and calm if you’re rehearsing Questioning like a lawyer rather than an
anthropologist When you’re working harder than the client Being impatient or intolerant of silence Mismatching your approach to client’s actual stage
of readiness to change
Road blocks to student care
If ever in doubt, refer out Most self-harm takes 12 mo+ to treat effectively Emphasise confidentiality Validate ambivalence about seeking help & keep
encouraging Achievable goal in short-term for most students is (1)
waiting skills and (2) reducing frequency (rather than cessation)
Referring out
Responding to Crisis flowchart Basic Distraction Techniques Handout for Parents Quick Facts about self-harm Tips and strategies for adolescents Tips and strategies for younger children
Worksheets and Handouts
Self-harm is almost always non-suicidal Maladaptive but effective coping strategy Is a way of communicating distress The psychophysiology of self-harm is very powerful Is incredibly difficult to treat. Follows similar
patterns to other addictive behaviours Addressing motivation to change is crucial first step It must be the individual’s choice to stop, you cannot
make someone stop
Summary
Familiarise self with facts, practice neutral communication
Differentiate immediate crisis from more mild or intermediate events
Consider how to make transition from self-harm incident back to regular activities more seamless
Consider how to tackle cliques (talk to each member one on one to reduce contagion)
Remember to reflect and address own self-care
Summary
0= NOT AT ALL CONFIDENT 1= SOMEWHAT CONFIDENT 2= CONFIDENT
How confident do you feel: Working with students who have engaged in self-harm? Being able to differentiate a crisis from more intermediate
and mild incidents? Understanding best-practice treatment approaches for self-
harm? That you could handle a crisis?
Post-workshop reflection
This time of year is usually the beginning of ‘peak’ self-harm trends in schools
Do you need further support, coaching or guidance about how to manage self-harm in schools?
Just need someone external to school to bounce ideas off?
Individual supervision via Skype or at our Port Melbourne office is available
Supervision
top related