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October 1, 2015
Vol. 73
No. 2

Self-Injury: What Educators Need to Know

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For many students, the transition to young adulthood comes with intense emotional experiences, such as the thrill of a first love and the pain of a first heartbreak. When learning how to cope with this new phase of life, some teens find themselves overwhelmed. Many harmful behaviors, including self-injury, stem from these teens' frantic efforts to relieve a painful emotional state.
Data from anonymous surveys reveal that about 15–20 percent of teenagers have engaged in self-injurious behavior, such as cutting (Walsh, 2012). Although self-injury is not necessarily a suicide attempt, it puts a student in a higher risk group for suicide (Linehan, 1993; Walsh, 2012). That's one reason it's important to understand self-injury and how to address it.

Why Do Students Engage in Self-Injury?

The first step to stopping self-injury is having a shared understanding of why these behaviors occur. Many people engage in this behavior as an attempt to relieve intense emotional pain. In the moment, cutting is their best effort to manage emotional distress. However, alternative strategies are available and effective. Dialectical behavioral therapy, for example, is a cognitive behavioral therapy developed by Marsha Linehan (1993) that specifically targets self-injury.
Dialectical behavioral therapy teaches distress tolerance skills (discussed in Linehan, 2015, pp. 420–492), alternate ways of dealing with emotional pain without engaging in risky behavior. Most people use distress tolerance skills without knowing it. Common examples include taking a deep breath when stressed, going for a run after a frustrating day, or venting to a friend. Distraction, a very common distress tolerance skill, can include watching TV, listening to music, doing puzzles, reading, or engaging in any other enjoyable activity. Imagining a safe place or doing relaxation exercises, such as progressive muscle relaxation, may also be helpful. Experiences that engage the senses, such as using a favorite hand lotion or eating a small piece of a favorite food, can also increase self-soothing. A small piece of high-quality chocolate can be very comforting!
If a student who is self-injuring is already engaged in outpatient therapy, school staff must coordinate with the student and his or her therapist to ensure access to distress tolerance skills at school. For example, a student may need access to a quiet place and a portable music player that he or she can use when overwhelmed to calm down and then return to class.

How Should Schools Approach a Student Who Is Self-Injuring?

When school staff members discover that a student is self-injuring, they should be calm and prepared. Designate a trained staff person who is responsible for meeting with the student and assessing the situation. A sample school protocol for determining what steps to take can be found in Treating Self-Injury: A Practical Guide by Barent W. Walsh (2012, pp. 297–298).
It's important to assess the type of self-injury as well as its frequency and severity (Walsh, 2012). High-risk self-injury includes severe self-injury requiring medical attention (usually stitches) and self-injury that occurs on the face, breasts, or genitals. Given the link between suicide and self-injury, the counselor should assess suicide risk by asking the student about suicidal ideation, history of suicide attempts, history of psychiatric treatment, family history of mental illness, access to firearms, substance use, sexual risk-taking, and symptoms of other mental illnesses, as well as any recent losses, including deaths of family or friends, break-ups of romantic relationships, or recent suicides in the community (Fowler, 2012; Linehan, 1993). It is equally important to ask about protective factors, including reasons for living and community supports (Fowler, 2012; Miller, Rathus, & Linehan, 2007).
A student with high risk of self-injury or at imminent risk of suicide should be evaluated immediately in an emergency room. However, a student who is not suicidal and has been self-injuring to cope with distressing emotions would benefit more from a referral to outpatient treatment. If an outpatient referral is recommended, it is important to follow up with the student's parents or guardian to make sure the student is connected to the appropriate resources.
When contacting parents, emphasize that the student is not in trouble. The purpose of the phone call is to ensure that the student has adequate support. It may be helpful to allow the student to be present during this phone call so that he or she knows exactly what information was communicated. If the parent or guardian repeatedly doesn't follow through on recommendations for mental health treatment, the school administration may consider filing for medical neglect.

What Kind of Counseling Should Staff Provide?

A designated adjustment counselor or school psychologist with expertise in self-injury might meet regularly with students who self-injure or answer questions students and staff have about self-injury. These two examples show how a counselor might address self-injury.

A Student in Distress

Susan is a 13-year-old girl who has been meeting with the school adjustment counselor every month because of trouble with schoolwork and arguments with her father. During their session, Susan discloses that after her most recent fight with her father, she cut herself on her left wrist with a razor blade. She did not need stitches.
A<EMPH TYPE="5">djustment C<EMPH TYPE="5">ounselor (AC): How often have you been cutting yourself?S<EMPH TYPE="5">usan (S): I started a few months ago. At first, it was just a few times, but now it's whenever I'm upset. I just get so angry, I don't know what to do. I've never told anyone.AC: Well, I'm really glad you told me. Have you done anything else to hurt yourself?S: Like what?AC: Like burning yourself, pulling your hair, or picking your skin?S: No …. Well, sometimes I pick at scabs.AC: Have you ever been so upset you wished you were dead?S: Well after one really bad fight, I went to bed and wished I never woke up.AC: You must have been feeling pretty bad. Do you feel like that now?S: No. That was a few months ago. But I have been feeling pretty sad since school started. I can't concentrate on my schoolwork, and I never want to go out with my friends anymore. Nothing feels fun.AC: Sounds like you've been feeling depressed. Have you ever thought about suicide?S: No, I would never do that.AC: Why not?S: Well, because then I wouldn't have a future. I really just want to go to college and move out of my house. Then my dad can't boss me around anymore.AC: I think that makes a lot of sense. Have you been drinking alcohol or using drugs?S: No way!AC: Do you or your parents have a gun at home?S: No.AC: Have you ever seen a counselor outside of school?S: No. (pause) Are you going to call my parents?AC: Don't worry, you're not in trouble. But I need to call your parents to get you some help. Would you like to be here while I call?S: OK.
The adjustment counselor then notifies Susan's mother with Susan in the room. She outlines her concern, emphasizing that this is not a disciplinary phone call. Susan's mother agrees for Susan to see a therapist outside school. They plan a follow-up call in one week, and Susan agrees to connect back with the school adjustment counselor later that week.

Concerned Friends

Three girls come to the school adjustment counselor with concerns about their friend, Vanessa, who has made an increasingly dark and despondent series of posts on social media following the breakup of her first romantic relationship. They know that Vanessa has cut herself in the past, but they have never told anyone because they were sworn to secrecy. The adjustment counselor pulls Vanessa aside before her next class:
A<EMPH TYPE="5">djustment C<EMPH TYPE="5">ounselor (AC): Don't worry, you aren't in trouble. I just wanted to check in and see how you're doing.V<EMPH TYPE="5">anessa (V): (guarded) Why? I'm fine.AC: Well, a few of your friends told me they were worried about you. They noticed you were really sad, and they've been worried about some comments you posted on social media. They also said that you've been cutting yourself.V: Who told you? They promised they wouldn't tell! They're not my friends anymore!AC: I think they care about you too much to let you go through this alone. I read some of your posts, and it sounds like you've been really down.V: (tearful) Yeah.AC: Have you been so sad you wish you were dead?V: Sometimes.AC: Have you thought of suicide?V: (Nods)AC: What have you thought about?V: I have some pills set aside at home for if things get any worse (starts to cry).AC: I'm really glad you told me how bad things have been. This is really serious.V: Are you going to call my mom?AC: Yes. This is an emergency, and you need to be seen in the emergency room.
Vanessa's mother is contacted and reports that she has also been concerned. Vanessa is seen in the emergency room and then admitted to the inpatient unit and connected with an outpatient therapist after she is discharged.

What Else Can Schools Do?

Self-injury can be stigmatizing, and it's important to have a calm, nonjudgmental stance when discussing self-injury with students. Never call students manipulative or make statements like, "You're doing this for attention!" Instead, reflect back the student's distress and need for support with statements like, "I can see you're really hurting, and I really want to get you some help."
Self-injury can spread from one teen to another, a phenomenon called social contagion (Walsh, 2012). Two important interventions to combat this are requesting that students who self-injure not share the details of self-injury with friends and requesting that they wear clothing that covers their wounds. Students who self-injure often comply with these requests as they do not want to harm or trigger their peers.
To further limit social contagion, treatment for self-injury should be largely individual. Groups for students who are self-injuring should focus on alternate coping skills and not delve into the details of self-injurious behavior.

A Large Responsibility

School staff in charge of assessing students with self-injury have a large responsibility, and it is imperative that the administration support them with training and materials needed to competently and confidently assess these difficult situations. They should also have access to clinical support, such as a peer supervision group or a clinical consultant with whom they can discuss difficult cases.
School cultures promoting acceptance and inclusion can also indirectly target isolation and loneliness, two emotional states frequently seen in individuals who self-injure. It's important that a trained counselor act as a point person for students who self-injure, but everyone in the school can be involved in promoting a culture in which students feel safe and supported.
References

Fowler, C. F. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49(1), 81–90.

Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.

Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New York: Guilford Press.

Miller, A. L., Rathus, J. H., &amp; Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. New York: Guilford Press.

Walsh, B. (2012). Treating self-injury: A practical guide (2nd ed.). New York: Guilford Press.


Nancy Rappaport is associate professor of psychiatry at Harvard Medical School and a consultant in the psychiatry department at Cambridge Health Alliance. She is the author or coauthor of several books, including The Behavior Code: A Practical Guide to Understanding
and Teaching the Most Challenging Students
(Harvard Education Press, 2012).

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