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Self-Injurious Behavior in Adolescents. WJCIA Annual Training Conference Stevens Point September 28, 2007. Kay F. Heimerl, MS LCSW Outagamie County DHHS (920)832-5270. Self Injurious Behavior. How will you know I’m hurting If you cannot see my pain?

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self injurious behavior in adolescents

Self-Injurious Behavior in Adolescents

WJCIA Annual Training Conference

Stevens Point

September 28, 2007

Kay F. Heimerl, MS LCSW

Outagamie County DHHS


self injurious behavior

Self Injurious Behavior

How will you know I’m hurting

If you cannot see my pain?

To wear it on my body

Tells what words cannot explain.

- C. Blount

  • An injury to one’s own body, done without suicidal intent or intent to attain sexual gratification.
  • Self-inflicted harm is enough to cause tissue damage.
  • Not part of spiritual ritual or for ornamental purposes.
  • Done as a way to alter a perceived intolerable mood state.
  • 3 million Americans
  • 1% of the general population
  • Males and Females
  • Middle class and educated
  • History of abuse and/or trauma
  • Often starts in early teens, peaks from ages 18-24, decreases in 30’s and 40’s
methods of sib
Methods of SIB
  • Cutting
  • Burning
  • Scratching
  • Picking
  • Interfering with wound healing
  • Head banging
  • Hitting self
methods of sib cont
Methods of SIB cont…
  • Breaking bones
  • Hair pulling
  • Spooning
  • Eating harmful objects – lightbulbs, glass, plastic
  • Ingesting chemicals
  • Over/under eating
comorbid behaviors
Comorbid behaviors
  • Reckless driving
  • Unprotected sex
  • Shoplifting
  • Promiscuity
  • Substance abuse
  • Eating disordered behavior
wound severity
Wound Severity
  • Extent of the damage
  • Level of medical intervention required
  • Location of the wound
high risk groups
High Risk Groups
  • Emotionally disturbed children
  • History of trauma/abuse
  • Borderline Personality Disorder
  • Young males with psychosis
  • Gender identity disorders
  • Dissociative disorders
high risk groups cont
High Risk Groups cont…
  • Substance abusers
  • Teens whose parents are physically or emotionally unavailable to them
  • Teens with untreated depression or anxiety
purpose of sib
Purpose of SIB
  • Relief from psychological pain
  • Release of tension
  • Affect regulation – can’t feel, feel too much
  • Communicate feelings – anger, sadness, pain, etc.
purpose of sib cont
Purpose of SIB cont…
  • Way of being in control
  • Defense mechanism
  • Feel the need to be punished
  • To be unattractive
  • Endorphins of physical pain cover up the emotional pain
  • “Event marker”
attention seeking
Attention seeking???
  • Not usually
  • Sometimes done to induce rescuing behaviors in others
  • Can provide an opportunity for self-care afterwards
attention seeking17
Actually it is often under-diagnosed and under-reported due to:

Shame, guilt, fear, pride

Learned distrust of others

Fear of legal consequences

Mixed feelings about treatment/recovery

Attention Seeking???
sib is often preceded by one or more of these emotional factors
SIB is often preceded by one or more of these emotional factors:
  • Depression
  • Stress
  • Hopelessness
  • Powerlessness
  • Purposelessness
  • Anxiety
  • Fear
psychological characteristics of self injurers
Psychological characteristics of Self Injurers
  • Invalidate self
  • Hypersensitive to rejection
  • Pervasive anger
  • Tend to suppress anger
  • Impulsive
  • High levels of aggressive feelings
  • Act on immediate mood
psychological characteristics cont
Psychological characteristics cont . . .
  • Feel powerless over how or whether they cope with life
  • Not future-focused
  • Depressed/suicidal/self-destructive
  • Anxious
  • Lack of coping skills
  • Avoidant
how should we react
How should we react?
  • Don’t ignore it!
  • Always take it seriously.
  • Don’t judge!
  • Show concern.
  • Stay calm and sincere.
  • Don’t overreact, rescue or “hyper-nurture”.
how should we react22
How should we react?
  • Remember that it is a cry for help.
  • Find out what is going on beneath the behavior.
  • Listen! Listen! Listen!
  • Don’t punish! Any interventions should be designed to protect, not to punish.
  • Acknowledge the SIB as a survival strategy.
how should we react23
How should we react?
  • Assess the extent of the injury and intervene appropriately.
  • Let them know that it is OK to talk about their SIB.
  • State that you cannot talk to the person while they are injuring because you care about them and it hurts you to see that.
how should we react24
How should we react?
  • Do not use ultimatums – i.e. stop or else!
  • Set reasonable limits.
interventions referrals


You must find something to replace the behavior. You can’t just take it away.

interventions referrals26
  • Psychotherapy – many methods and interventions
  • Trauma work – therapy, PTSD Workbook, EMDR
  • Contracts – agree to try alternate behaviors before SIB
  • Alternate behaviors need to be harm reducing – rubberband snapping, hands in ice, chewing cinnamon or hot peppers, etc.
interventions referrals27
  • Medication
  • Develop Personal Validation
  • Spirituality
  • Meditation
  • Yoga, Tai Chi
  • Appropriate physical releases
interventions referrals28
  • Group therapy – DBT, Abuse survivors
  • Family therapy
  • Change core beliefs and values
  • Teach emotional literacy – feeling lists, journaling
  • Safety bag
safety planning
Safety Planning
  • Assessment questions
    • Do you need to hurt yourself? What has brought you to this point?
    • Have you been at this point before? What did you do then to deal with it? How did you feel then?
    • What have you done to ease this discomfort in the past? What else can you do that won’t hurt you?
safety planning30
Safety Planning
  • Assessment questions cont…
    • How do you feel right now?
    • How do you feel after hurting yourself? How will you feel tomorrow morning?
    • Can you avoid this stressor, or deal with it better in the future?
safety planning31
Safety Planning
  • Contracts
    • List alternate behaviors to use before SIB
    • Names and numbers of contact persons
    • When to call Crisis
    • When to seek medical attention
    • Discuss placement options ahead of time if possible – i.e. hospital, crisis bed, secure detention, family member, etc.
safety planning32
Safety Planning
  • Decide who will be included in the contract – parents, school personnel, mentor, physician, etc.
  • Determine length of contract viability
  • Be clear about mandatory reporting obligations and potential consequences
  • Consult with Mental Health professional