Self Injury Within Schools: Intervention, Ethics, and Legal Considerations.

1. Self Injury Within Schools: Intervention, Ethics, and Legal Considerations. Dr. Terry McQuaid, Psy.D., C.Psych. Provincial Dialogue 2008 York University, Toronto Ontario

2. Introduction • Self injury (SIB) is defined as a coping strategy for dealing with overwhelming emotional pain. • Adaptive and meaningful behaviour • Coping Mechanism • Intention is gaining relief from internal distress. • Question? Background & Interest of Audience • Learning Objectives.

3. Learning Objectives • Introduction • Frameworks to used to understand SIB in youth and adolescent groups. • Ethical and Legal Considerations around SIB involving minors. • Case Examples. • Counsellor’s role and suggested interventions.

4. Overview Given the prevalence of SIB in the youth and adolescent populations, school counselors are placed in an important position. From such a position counsellors… Recognize the signs and symptoms. Actively access & develop the knowledge required to appropriately intervene. Signs Emotions Culture Symptoms Sociopolitical Risk Factors School Policies Legal Ethical Kress et al., 2004

5. Risk Factors Associated with SIB • In Adults • A history of self-harm • Unemployment • Alcohol and drug-related problems • A general sense of hopelessness

6. Risk Factors Associated with SIB • In Adolescents • Eating disorders • Physical, emotional, psychological or sexual abuse • Depression, paranoia or obsessive-compulsive disorder • Low self-esteem and self-worth • Bullying

7. Self Injury: Implications for Action • Self-injury is not a suicidal gesture or an attempt. • It involves physical injury to the body which can lead to health consequences (ranging from mild to serious), and • Individuals who engage in self injury may • become dependant on this form of coping when other strategies are scarce, • be despondent and experience a wish to commit suicide, and • lead to an accidental completed attempt. Deiter & Pearlman, 1998

8. Prevalence Rates • 20% of individuals (across all ages) in primary care seeking psychiatric or psychological assistance admit to engaging in some form of self-injury. • 4% of general population and 14% of high school students engages in self-injurious behaviour. • Adolescents are not emotionally cut-off or numb rather they have difficulty finding the “actual” words to express their internal experience. Psychotherapy Networker July August 2006

9. Frameworks to Understand SIB In youth and adolescent groups these include • Socio-political dynamics • Cultural factors • Emotional factors • Gender and SIB. • Exercise Psychotherapy Networker July-August 2006

10. Sociopolitical DynamicsExample Latino Girls and Suicide • The Problem 24% of girls in this group seriously consider suicide and 15% made an actual attempt. [Higher than rates for African Americans, European Americans]. Six to Eight times more likely to make a second attempt. • Substance Abuse and Mental Health Services Administration (SAMHSA, 2003) cite 283,000 Latina girls between 12 to 17 years were at risk for suicide. Psychotherapy Networker July-August 2006

11. Higher rates of completed suicide in population of Latino Girls…Why? • NIMH study lead by Luis Zayas reports strong family ties of Latino families actually “contributes” to the suicide attempts. • He calls the “family structure vs. adolescent autonomy” a pressure cooker. • It creates confusion and guilt within these young women around social mores/family unit and today’s teen culture (hormones/desire). • Research related to contagion implies that social factors may contribute to the development and maintenance of self-injurious behavior (Deiter & Pearlman, 1998 Psychotherapy Networker July-August 2006

12. Cultural Factors • Latino girls - SIB often occur around a boyfriend, romance, break-up sexual activity etc. • Same pressures exist for Asian women but the rate of SIB is considerably lower. • Theories and findings are in state of constant evolution (norms from the past may not meet the needs of today’s teens so stay current). Psychotherapy Networker July-August 2006

13. Emotional Factors • Plus emotional and physiological changes associated with adolescence exacerbate and/or place additional strain on under-developed coping strategies. • Need to develop a good understanding of their needs and reactions. • ‘The Divided Self’ • emotions and natural innate curiosity (internal fantasy) • 24/7 “plugged-in, interactive fantasy world” that offers immediate gratification on all levels. • Declining interests in family/world history has eroded longitudinal perspective (i.e. moment-to-moment feedback and fantasy). • Deterioration of coherent sense of self within. National Inquiry into Self Harm, September 2004

14. Gender and SIB • Understanding Adolescent Boys • Often use monosyllables and sarcastic clips. • Expulsion, incarceration, neglect, abuse, chaos and conflict etc. • No palpable sense of urgency when dealing with these issues in counseling. • Have difficulty communicating and/or expressing feelings in general.

15. Gender and SIB • Understanding Adolescent Girls • Adolescent girls are clamoring to be heard and seen (felt) in their own right. • It may not feel like it as the recipient – but these girls long to build relationships (with you); and vocalizing insults is the young woman’s attempt and doing so and then to “seeing” if you can tolerate their demand for relatedness.

16. Girls and SIB con’d • These girls can, and often do come in with a diatribe of situations and life stories around relationships and metaphorical bags containing items that provide clues to their inner lives. • Some of these gender stereotypes around communication patterns and feelings are true but they’re not without exceptions. Deiter & Pearlman, 1998

17. Counsellor’s Role • Work to ensure students have a safe place to develop emotionally and academically. • A personal awareness and understanding of one's intentions (i.e. seek consultation peers, administration, community resources). • Advocate for adolescents through in-services activities, parenting groups, and speaking with students in health classes to dispel common myths around SIB.

18. Ethical and Legal Considerations • Confidentiality and Responsibilities to Students, Schools and Parents. • Professional Competence • No-Harm Contracts • School Policies on Self-Injurious Behaviors • Vignette 1 & 2

19. Confidentiality and Responsibilities to Students • Ethical standards obliged counselors to keep student reported information confidential unless the student is in imminent danger to self or others. • Adherence to ethical guidelines around sharing student information around SIB through written or verbal communications. ACA, 1995; ASCA 2004

20. Confidentiality and Responsibilities to Parents and School Systems • Responsibility to parents and the school administration supersedes ethical guidelines unless confidentiality laws exist in a state. • Rights of parents and school administration to access confidential information in a student file. ACA, 1995; ASCA 2004

21. School Policies on Self-Injurious BehaviorsProfessional Competence • Examining existing policies around self-injurious behaviours and becoming knowledgeable around it’s practical implications in the counseling students. • Policies around SIB should have built-in flexibility given the great deal of variability in the underlying dynamics, issues, and needs of students who self-injure. • Consultation with legal counsel which is accessible, timely, and up to date with issues related to adolescents behaviours and needs in an academic setting. • Anticipating ethics-related concerns will help prevent ethical problems when working with self-injurious students. ACA, 1995; ASCA 2004

22. No-Harm ContractsProfessional Competence • Behaviours which lead counselors, parents, administrators to take action (what action). • Developing alternative coping strategies in conjunction with individual students and/or as part of a classroom learning objective (i.e. health class). ACA, 1995; ASCA 2004

23. Treatment/Intervention • Safety –empathy, trust, containment and verbal expression • Positive substitution - “rainy day box” • Distractions relaxation strategies • Recognizing, minimizing and/or avoiding triggers. • Developing self care skills • Being consistent • Acknowledge your error • Create space for hope.

24. Treatment/Intervention con’d • Built communication skills which translates to psychological resilience. • Can’t alter the present impact of technology and it’s interaction with teen culture. • Goal is to built the “edge of relatedness” – termed by Darlene Ehrenberg as a mechanism for assisting adolescents to heal their divided selves. Professional Student Counselling 2006

25. Treatment/Intervention • Current society is majorially dependant on the intricacies of language and communication. • Uncommunicative boys = “treatment resistant”. • For some boys - self expression may be experienced as “coming apart” hence they use so strategies like withdrawal and silence to prevent destabilization and confusion. • Media = Electronic Alter ego further alienates and encourages withdrawal. Psychotherapy Networker July -August 2006

26. Summary • Self injury behaviours (SIB) are not a cry for help or a suicide attempt. • Rather SIB are an indication that the youth and/or adolescent is struggling to deal with and verbalize difficult emotions (representative of their internal state). • School policies should be dynamic and flexible in order to address the variability and acuity of how many of these situations present them self. • The counsellor’s role is a pivotal one in terms of detection and intervention. • Challenge exists in acting in a safe responsive and ethical/legal manner for all parties concerned; but this is especially so in the case of the most vulnerable person – the student.

27. References • Ace's (1995) Code of Ethics and Standards of Practice. • ASCA's (2004) Ethical Standards for School Counselors. • Deiter, P. J., & Pearlman, L. A. (1998). Responding to self-injurious behavior. In R M. Kleespies (Ed.), Emergencies in mental health practice: Evaluation and management (pp. 235-257). New York: Guilford. • Kress, V. E., Gibson, D., & Reynolds, C. (2004). Adolescents who self-injure: Implications and strategies for school counselors. Professional School Counseling, 7, 195-201. • Professional Student Counselling. Students who self-injure: school counselor ethical and legal considerations. December 01, 2006. • Psychotherapy Networked, July-August 2006. • The National Inquiry into Self-Harm, September 2004 United Kingdom [Adapted from http://www.selfharmuk.org/facts0.asp].

28. Where to Get More Information • •Women’s College Hospital (Mental Health Clinic)-(416)323-6440 • •Sick Children’s Hospital (Teen Clinic) (416) 813-5804 Susan Murphy • •North York General (Adolescent Clinic) (416) 756-6642 • •Sunnybrooke Hospital (Adolescent Clinic) 416-480-4098; Adult (>19) 416-480-4089. • •Credit Valley Hospital (Partial Hospitalization Program) • •CAMH DBT Clinic416-535-2437* One time consultations only.

29. Suggested Readings • By Their Own Young Hand Deliberate Self Harm and Suicidal Ideas In Adolescents. Hawthon, Rodham and Evans. • Adolescent Self-Injury: a Comprehensive Guide for Counselors and Health Care Professionals. Amelio D’Onofrio