Self-Harm and Self-Injury

Definitions

Self-harm (also known as self-injury ) occurs when a person causes intentional harm to himself. Many self-injurious behaviors present a high risk and could result in death. People who engage in self-harm behaviors are at a higher risk for attempting suicide.

Common ways that people engage in self-harm or self-injury include (but are not limited to):

• Scratching, cutting, or burning their skin (often on the wrists, arms, legs, or chest).
• Hitting, banging, or bruising parts of their body (often on the head, stomach, or legs).
• Choking, strangling, or hanging themselves for a brief period of time (i.e., self-asphyxiation) to enjoy the “high” associated with the decrease in oxygen reaching the brain.

Individuals may engage in self-harm or self-injury as a way to:

• Feel emotions or have a sense of control.
• Express or relieve extreme or overwhelming emotions.
• Seek attention (though this is not the case for all instances of self-harm behavior).
• Gain admission or acceptance within a peer group engaging in self-harm.
• Reject parental or community values.

Individuals who engage in self-harm or self-injury typically are experiencing or struggling with something that is causing them psychological distress (e.g., anxiety, anger, or depression). Self-harm is often a way that they cope with emotional distress or express their internal experience.

If the source of the stress is not addressed or resolved, the self-harm may become a pattern.

Never leave the client alone if you have to leave the room. Instead, ask another clinic employee to sit with the client or ask the client to walk with you if possible (e.g., if you are getting something from the printer).

Providing clients with a safe space to experience and express their emotions will help them develop more healthy coping skills and ways for communicating their emotions. Talking with a client about self-harm behaviors should be done without expressing disapproval or making the child feel ashamed.

Rather than focusing on getting the person to stop engaging in self-harming behaviors, focus on promoting healthy coping strategies (e.g., deep breathing, journaling, exercise) during times when they might usually resort to self-harm behaviors.

Be aware of and communicate the limitations of confidentiality.

• If at any point in time you become aware that the client has an intention of committing suicide, you may need to breach confidentiality for the client's own safety.
• See Chapter D-6: Suicidal Thoughts and Plans and Chapter B-5: Mandatory Reporting and Duty to Warn.

Self-harm is often an attempt to cope with stress or other emotional experiences. Acts of self-harm or self-injury are often seen in individuals who have past experiences with trauma or abuse. With help, people who engage in self-harm can learn more positive ways of coping with and expressing their emotions.

• If not addressed early on, these behaviors will likely continue or return in times of stress.
• People who engage in self-harm benefit from regular support and opportunities to express and experience their emotions in safe and healthy ways.
• Encourage them to talk to you about what is bothering them.
• Work with them to understand and address the various reasons why they are engaging in self-injurious behaviors.

Display genuine concern about self-harm. If a client is engaging in a self-harm, refer the client for a medical evaluation.

Usually self-harm or injury is not done with the intention of committing suicide. However, in some cases, it may be an early sign of suicidal thinking.

Substance abuse can impair people's thoughts, cloud their judgment, and affect their emotional state. Clients under the influence of drugs or alcohol are at increased risk to self-harm. If your client is under the influence, follow your organizational policy on how to respond to an intoxicated person.

When working with minors who are engaging in self-harm, remember:

• Sometimes children or adolescents might be involved in risky or self-injurious behavior without considering the possibility that it could result in their death.
• Children and adolescents who are developmentally disabled or autistic may engage in self-injurious behaviors. Work with the provider who is addressing the disability and/or with your supervisor when supporting these clients.
• Youth who are experiencing problems with self-harm or injury will do best in individual sessions.

Note that tattooing and body piercing are usually not considered to be acts of self-harm or injury.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history, including past therapy, hospitalizations, out of home placements, or any current medications.

Treatment Plan, including a history of the presenting problem and recommended course of treatment.

Physical symptoms

• Frequently has new cuts, scratches, burns, or bruises
  • If these are visible, they are usually on the client’s non-dominant side (e.g., a right-handed person is more likely to show injuries on the left arm)
• Often wears long-sleeved shirts/tops and pants to cover up, even in hot weather
• Has several odd scars or marks around the lips or on the arms, legs, or stomach

Emotional/behavioral symptoms

• Expresses feelings of shame, worthlessness, self-dislike, and/or being unlovable
• Behaves impulsively or can be emotionally reactive
• Has trouble expressing or experiencing emotions
• Is emotionally unstable or unpredictable
• Feels hopeless about the future

Other related factors

• Avoids social situations
• Has limited social connections
• Is struggling with social or academic issues at school
• Is being bullied and/or is bullying others
• Is socially withdrawn or isolated
• Experiences rejection
• Has objects and materials related to self-harm behaviors (e.g., razor blades or other cutting instruments)
• Is conflicted or confused about issues related to own sexuality (e.g., sexual orientation, gender roles, or sexual activity, including having been sexually victimized)
• Has a history of trauma or abuse
• Is dealing with loss in a significant relationship (possibly due to death, divorce, abandonment, or a breakup)
• Is troubled by social problems (family, social, or community)

Severity of self-harm behaviors

• Tell me how you hurt yourself.
  • How often have you tried to hurt yourself?
  • When was the first time you hurt yourself?
• Tell me why you hurt yourself.
  • What do you feel and think about when you hurt yourself?
• What is usually going on before you feel like hurting yourself?
• What certain times or experiences lead you to want to hurt yourself more?
• What parts of your life do you wish could be better?
• What are you looking forward to in the future?
• Have you ever hurt yourself bad enough to require medical care?
• Sometimes, these self-harm behaviors are very dangerous and can lead to intentional or unintentional death. Do you ever think about death when you are harming yourself?

Suicidal thoughts and plans

• Have you ever hurt yourself with the intention of killing yourself? If yes, ask:
  • How did you do this?
  • What happened?
• What do you believe will happen if you died as a result of hurting yourself?
• How might your friends or family members feel if you died as a result of hurting yourself?
• What are some other possible solutions to your problems?
• What have found to be helpful in dealing with these problems?
• Who have you felt comfortable talking to about your self-harm behaviors?
• If you haven’t told anyone else, is there someone you trust that you think you could tell?

Contributing factors

• Tell me about your home/school life.
• What, if any, problems are you having at home/school?
• How are you getting along with others in the community?
• Have you ever been hurt or picked on by anyone?
• Do you feel alone or lonely most of the time?
• How do people get along in your home?

Routinely review Chapter C-4: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

Specifically, you may consider utilizing different DBT skills and activities to help clients respond to and manage their emotions in a healthy way. Completing a "Chain Analysis of Problem Behavior" will help you and the client understand what happens immediately before a person self-harms or self-injures and what the self-harm behavior leads to. Other DBT-based interventions that may be beneficial include:

• Mindfulness Skills. These strategies help people calmly be aware of the emotions and physiological symptoms that are leading them to self-harm.
• Emotional Regulation Skills. Understanding and naming emotions can be a good starting point for individuals experiencing emotional flooding and reacting behaviorally through self-harm.
• Distress Tolerance Skills. Once individuals are able to identify their emotional experiences, they can be taught specific distress tolerance skills to use instead of engaging in self-harm. Some examples could be vigorous exercise, distraction, or thinking strategies like cognitive restructuring/reframing.

Be sure you are familiar with the information in Chapter B-5: Mandatory Reporting and Duty to Warn and Chapter B-8: Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.
• Note: If the client has injuries that require medical attention, immediately refer her to a medical professional or local CHAP.