Counseling Clients Who Self Harm

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you I'd like to welcome everybody today's presentation on counseling clients who self harm. I am Dr. Donnelly Snipes and I am your host. Today we're going to be talking about defining self injury and self harm versus not and differentiating suicidal self injury from non suicidal self injury and then talking about some interventions that, that we can work with. What's the difference between self harm and self suicide? Gosh. And suicide. There are big differences. The majority of people, not all of them, but the majority of people who self injure are actually not suicidal. And that's really important to remember now. They can accidentally go too far and you know, have deadly consequences or, and, or they could escalate to suicidality eventually. But just non suicidal self injury by itself does not necessarily mean that that client is actively suicidal. So we'll talk about that a lot as we go through this. So self injury and self harm is any voluntary behavior that intentionally injures or harms the body. Now I don't know how familiar y' all are with working out. Today was leg day for me. And when you work out, when you lift weight, you are intentionally causing micro tears in your muscles in order to build them up. You're intentionally hurting yourself, so to speak. And you walk out a leg leg day. Kind of like a baby giraffe, you know, not very coordinated. And you think this is the greatest thing in the whole world. I don't know. There's something wrong with this maybe. Is that self harm? No, our intention is not to damage the body permanently. Our intention is to break it down to build it up again. We really need to look at intentionality with behaviors. Some self injurious behaviors are done for reasons other than suicide. And we're going to talk about these as NSSI for the rest of the presentation. So I don't have to keep saying non suicidal self injury because I will trip over my own tongue. But some of the reasons people engage in NSSI are distress tolerance and emotion regulation, attention seeking, absolution from demands, and you know, there are a variety of other reasons, but these are three of the big ones. One of the biggest differences between NSSI and suicide attempts is that suicide attempts involve a conscious intention to die. The objective of NSSI seems to be to relieve unbearable pain or a sense of powerlessness. And we're going to Talk about how that happens. The intent of NSSI is to feel better. NSSI methods are generally not lethal. When you think about self injury, the most common thing people think about is cutting. But there are lots of forms of self injury. I worked with several clients, unfortunately who when it came time for the standardized test every year, they would get so stressed out because the teachers had put so much pressure on them and in this particular school system that they would start pulling out eyebrows or eyelashes or pulling off hair, you know, Trichtillomania would become an issue for them. That is a form of self injury. Scratching can be. So we're going to talk about those more later. But when we look at NSSI methods, they're generally not lethal. You're not going to commit non suicidal self injury with a gun. You're not going to typically overdose as a form of nssi. Now there are some people who do overdose and they try to do it just enough to get them in the hospital, but not enough to kill themselves. Those clients tend to, when I'm working with them, make me a lot more nervous because it can easily, very easily become lethal and they may not even know it till it's too late. I worked with a client once who overdosed on Tylenol and thinking that Tylenol wouldn't killer and it ended up doing severe irreparable damage to her liver. So there are many different forms of nssi. NSSI is used frequently compared to suicidal behaviors. Somebody who engages in NSSI is often using it sometimes daily, sometimes multiple times a day, sometimes once a week. When we look at clients who tend to become suicidal, it typically comes and goes, if you will. They will have a suicidal ideation and maybe a suicide attempt and then the next one may not be for six months or a year or two years or hopefully never. But suicidal behaviors are not something you see from somebody on a daily basis. The level of psychological distress is often lower in nssi. Like I said, if the NSSI does not address the underlying issue, if it doesn't give them some relief, then they may escalate. However, NSSI is often a stopgap or a way to mitigate or a way to prevent suicidal ideation. They're trying to get control in some way. We want to look at NSSI as a functional behavior to try to address something and we want to look at, you know, what's the function of the behavior, then we can find other ways of solving the same purpose. Linehan in her writings talks about when you work with someone who engages in NSSI and you want to help them find alternate behaviors. One of the things they can do is put their hand in an ice bath, hold ice cubes. Both of those things are very helpful, if you will, for. Managing non suicidal self injurious behaviors. Because the pain is there, they're controlling it. They are undergoing a lot of the same cognitive and physiological processes, but they're not causing damage to their body. People who are suicidal often see things very dichotomously. It's all good or all bad. I cannot live without this person, period. There's no gray area. There is no, unless this happens, it's I cannot live without this person or I cannot go on like this anymore, period. No options, nothing. People with NSSI tend to be less dichotomous. They feel like they cannot tolerate the current emotions, but somewhere in the back of their head they're like, if I can get this under control, I can keep on plugging. The aftermath of NSSI is often short term improvement. Well, let's think about it. They felt, for example, emotionally dysregulated, and the NSSI helped them get regrounded for a second. It helped them focus, it helped them maybe have have a sense of control. It released endorphins. So there may be a short term feeling of relief where the person's like, okay, I can breathe for half a second now. That's often followed by going back into the cycle again. But obviously with suicidal behaviors, there is no aftermath. The person has terminated their life. A little bit of note about BDSM and body modification, including plastic surgery, cosmetic surgery, piercings, tattoos, any of that, yes, those things can cause injury to the body. However, they're not considered NSSI unless the intent of the action was to harm the body. When people get tattoos, when they get implants, when they get cosmetic surgery, the intent is to express themselves in some way. Generally, the intent is not to harm the body. When people engage in what's called sensation play in bdsm, the intent is, is to push their limits and see what they can endure. The intent is to develop a stronger connection with their partner if they're doing it with a partner. So the intent is not. The primary intent is not to harm the body. The DSM 5 still includes sexual sadism disorder and sexual masochism disorder as potential diagnoses. But the diagnosis now requires the interest or activities to cause the person to clinically significant distress in social, occupational, behavioral functioning or that it's being done to another person without their consent. That makes sense. So the DSM 5 has recognized that some people do engage in sensation play and body modification. And if it's not causing them a problem, then it's probably not going to fall under the rubric of a diagnosis. Diagnosis. In nssi, people experience overwhelming negative feeling states prior to self injury. They're feeling out of control in some way. Then they feel relief and distraction during the NSSI activity, often followed by regret and shame. Okay, we've seen this in, most of us have probably seen this in our clients. You know, there are very few people who haven't worked with at least one client who engages in NSSI at some point. In contrast to that, BDSM practitioners who engage in sensation play feel excitement and anticipation ahead of time. It's like, oh, boy, okay, I'm going to see how much, you know, how far I can push my limits. I am going to test myself. They feel pleasure during the encounter, a sense of deep connection, and a stronger sense of empowerment and authenticity afterwards. They're getting to know. They feel like they're getting to know their true selves and their limits and all that stuff. So the reaction after BDSM type activities is very different than after nssi. Neither one of them is necessarily, well, the intent is what we're looking at. Some myths I wanted to dispel really quick. Only females self injure. No. 30 to 40% of people who self injure are male. And the data and statistics out there about people who are transgender versus cisgender and for people who are LGBTQ is greatly lacking. So what we're talking about is when we say females versus males, we're talking about the body that they're born into, not necessarily what they feel. NSSI is not a failed suicide attempt. It's often a means of avoiding suicide, but can accidentally escalate too far. So I don't want to minimize this and go, oh, you know, they don't intend to commit suicide. You don't need to worry about it. That's not true. They need to worry. You need to be aware of it. And it does need to be a significant treatment issue. And if you look at dialectical behavior therapy, one of the first steps is to make sure to stabilize the patient and remove any risk of suicide. Self injury, self injurious behavior, things are untreatable. No, that's not true at all. They can be treated. The key is, number one, motivation. The person has to want to stop, and number two, figuring out what is prompting the situation that triggers self injurious behavior. Everyone who self injures has borderline personality Disorder? No, absolutely not. Big? Huge. No. I worked with a lot of clients who have borderline personality disorder characteristics, but they don't meet the criteria for bpd. I have worked with people who have self injured, but they really don't have a lot of the criteria for borderline personality disorder. They just have really intense emotional dysregulation. Cutting is the only form of self injury. We already talked about that. And no. People who self injure enjoy the pain. No. When we're talking about non suicidal self injury, the pain or the act of self injury is a means to an end. And that end is to try to help them feel in control or get some relief. People who self injure are a danger to others. No, they are feeling out of control. And what are they doing? They are turning the injurious impulses upon themselves. They're not wanting to hurt anybody else. They're really not wanting to hurt themselves. They're just wanting some relief. NSSI is most common among adolescents and young adults and the age of onset is about 12 to 14 years old most of the time. So we want to really look at our middle schoolers and our high schoolers. The DSM 5 includes NSSI non suicidal self injury as a condition requiring further study. So the DSM 5 is starting to realize that this might be an issue. Prevalence rates and you're not going to be tested on this, but I wanted you to see how prevalent it actually is. Depending on the definition and depending on the sample that was chosen, anywhere from 7.5 to 46.5% of adolescents use non suicidal self injury to some extent. 38.9% of universities, university students engage in non suicidal self injury to some extent and 4 to 23% of adults. It doesn't necessarily go away. You see, there's a difference. Adolescence is 46.5%, truly. However, when people get past the adolescent stage, when they get into adulthood, which by the way, the prefrontal cortex doesn't finish developing until about 25 years of age, which is after we've graduated from college. And that is involved in a lot of emotion regulation and impulse control as a side note. But we see that the prevalence rates do go down in the adult population. There's a high correlation with trauma and comorbidity with many other mental or physical health disorders. When somebody engages in nssi, we need to be on the lookout for other stuff because it's probably not just an issue in isolation. Gratz and colleagues emphasized the role of parental relationship in the etiology of self injurious behaviors. He found that insecure paternal attachment and both maternal and paternal emotional neglect were significant predictors of NSSI in women. Looking at attachment theory, remembering that with secure attachments people people learn how to emotionally self regulate. If that initial attachment relationship goes south for some reason, we can see how someone might more easily or more strongly emotionally dysregulate, which could be correlated with nssi. NSSI in men interestingly, in this one study was primarily predicted by childhood separation, usually from the father. That was obviously only one study, but it was something to think about. An SSI is often an unhealthy approach to emotional regulation and distress, but the person doesn't want to die. The person is trying to do something to get some relief. They're trying to figure out how to fix it because nothing else has worked till NOW. For approximately 90% of patients, NSSI decreases symptoms or aids in dissociation from anxiety, depressed mood, racing thoughts, anger or flashbacks. NSSI may generate desired feelings as well. Power I have the power to feel Pain. I have the power to stop. I have the power to endure this pain. Control Euphoria is another feeling because when we experience pain, what happens? Our body sends out endorphins and our natural painkillers. So people get a euphoric rush. You can liken it to the runner's high if you will. And sometimes people engage in NSSI just to feel something because they are so alexthymic. They are so unable to feel like they feel anything that at least this gives them something to feel so they realize that okay, I'm still here. During periods of grief, insecurity, loneliness, extreme boredom, self pity and alienation, NSI may also signal distress to elicit a caring response from others. High levels of negative and unpleasant thoughts and feelings are associated with NSSI because, well, it makes sense. NSSI is one way to cope with those things. Other risk factors for the development of NSSI so things that we can look at for prevention potentially include poor communication and problem solving abilities, trauma via abuse, maltreatment, hostility and marked criticism during childhood under or over arousal Responses to stress High valuation of NSSI to achieve a desired response. Some people place a premium on this. It's like, okay, let me show you what you're going to make me do. A need for self punishment or modeling behaviors based on exposure to NSSI among peers on the Internet like postings on YouTube and in the media. Remembering back many, many, many years ago. I can never think of the the movie where Glenn Close engaged in a lot of self injurious behaviors. Can you help me here? But anyway, that was a perfect example of fatal attraction. Thank you, Barry. That was a perfect example of using non suicidal self injury to try to get attention and try to get power and control. And a perfect example of almost pushing it too far. Interestingly, NSSIS are related to eating disorders. Both eating disorders and NSSIS affect how people feel and are often used as a way to change, express or suppress emotions. Okay, it makes sense. So similarities in individual factors between people with NSSI and eating disorders. High emotional reactivity, low distress tolerance or poor distress tolerance skills, impulsivity, perfectionism and high self criticism, Alexthymia, mood disorders and ptsd. All of these things have been correlated with NSSI and eating disorders. Similarities in social, low emotional support, high control and criticism. So not only are they criticizing themselves, they're getting a lot of control and criticism. Externally, low connectedness, a trauma history, body objectification or dissatisfaction, and cultural or peer pressures. In hazing, for example, in certain clubs there is body shaming that may happen and people may engage in self injurious behaviors in order to cope with that, or the club or group may promote self injurious behaviors. NSSIS and eating disorders can co occur. This is really important to recognize. They can alternate. If somebody's not engaging in an eating disorder, they may engage in NSSI and vice versa, or they can co occur or they may be independent. You can have somebody who has an eating disorder that doesn't engage in NSSI but be on the lookout for it for men and women. And again, please remember that borderline personality disorder is not the only diagnosis for these people. And oftentimes labeling somebody with BPD creates a sense of hopelessness and helplessness because old research indicated that it was not treatable. Borderline personality disorder characteristics, on the other hand, a lot of people have them working in addictions. A lot of clients that I worked with in their first six months, maybe a year of treatment evidenced a lot of borderline personality disorder characteristics. But as they became stronger in recovery, a lot of those things change, disappeared, if you will, or became less prominent. So being careful not to equate NSSI with borderline personality disorder is of utmost importance. So what are the functions of nssi? We've alluded to them a little bit. Escape both positive and negative reinforcement. Positive reinforcement is when you do something and you get a reward. In nssi, that's the endorphins. The endorphins are going wow. Negative reinforcement is when something unpleasant gets taken away. So you know, negative reinforcement at the dinner table is if the kid doesn't want to eat his vegetables and mom says, well, if you eat your main dish, then you don't have to eat your vegetables. That's negative reinforcement because something unpleasant, the brussels sprouts, got taken away. In nssi, negative reinforcement is taking away or the distraction from emotional or other pain or alleviating pressures from something. It can be a signal of distress to gain attention. Some people don't have the verbal capacities or the ability to say what's going on. If Sally's parents are fighting, then it's important to pay attention to or she may engage in these behaviors because she's trying to get attention on her. It's like, okay, if I do this, then maybe they'll stop fighting and they'll just shut up. If John broke up with Sally, Sally may engage in non suicidal self injurious behaviors in order to get attention because it hurts so bad that John broke up with her. Sam crashed his car when he was depressed. He was telling people he was depressed, but you know, nobody was really paying that much attention. So he went out and he crashed his car. That's potentially non suicidal self injury. There are ways. If you're going to wrap it around a tree, it's obviously a suicidal behavior. But if it's something else, then, you know, you need to look at the intent with the person attempts to remove distressing interpersonal demands or gain a sense of control. I told you before annual state testing, I would see children regularly start engaging in nssi during the test. They'd be pulling out their arm hairs or pulling out their eyebrow hairs. Football playoffs if somebody is, you know, really stressed out, they don't think that they can do what everybody expects of them. They may suddenly do something to sprain their ankle or they may do something to get them out of having to do the go to the football playoffs. If you're expecting a child to move out suddenly, the child may regress or engage in NSSI in order to avoid having to move out. And in an enmeshed family, somebody may engage in NSSI because it's like, well, you're controlling every other aspect of my life. Let me show you. This is the one thing I can control. And there are a lot of other examples, but those are just some that come out and self punishment. Sometimes people engage in NSSI as self punishment for abandonment or isolation. I knew I wasn't good enough and I should never have tried to do that for failure. If people fail at something, then they may injure themselves as a punishment or for survival to try to. They may feel guilty for surviving after, you know, a car crash. Maybe they were the one person in the car who survived. And they feel so guilty about it that they start engaging in NSSI because they don't feel like they should have lived. NSSI may fall within four descriptive categories. Major NSSI involves infrequent acts that destroy significant body tissue, such as eye enucleation or amputation of body parts. Most of these we generally don't see in treatment. 75% of the people who engage in major NSSI engage in those things during a psychotic state, mainly schizophrenia, sometimes depression with psychotic features, or sometimes in a manic episode of bipolar disorder. But 75% there is some psychosis there. Most times patients cannot articulate large logical reasons for their actions. They may say, you know, if they're having religious delusions, they may say, I cut off my hand because it was making me evil. Treatment for major NSSI is prevention above all, figuring out, especially if it's because of a psychotic state, how to get that psychosis under control and focusing on prevention. Not just pharmacological prevention, but lifestyle prevention. Because there are a lot of things that can trigger psychotic episodes, and antipsychotics are extremely sensitive to hydration levels. We used to see a great spike in the admissions to our crisis stabilization unit for people with psychotic disorders during homeless people during the summer in Florida because they'd get dehydrated and then their blood plasma levels of their antipsychotic would be out of whack. Paying attention to that, if it's occurring in the midst of a psychotic episode, no amount of cognitive behavioral is really going to do a whole lot of good until you get that psychosis under control. Do look out for sudden shifts in behavior or appearance which might indicate the beginnings of a psychotic episode. Again, including major depression without or major depression with psychotic features or a manic episode. A lot of times the to answer your question, Patricia, the attempts to remove distressing demands is conscious, intentional. Sometimes it's subconscious, but most of the time the person is trying to figure out a way to get people to listen or to get people to leave them alone. Stereotypic NSSI includes repetitive head banging, eye gouging, lip biting or biting, the tongue, cheeks or fingers, or face or head slapping. This can include stimming when the stimming is injurious. And this is stimming is something that people with autism may engage in. These behaviors are monotonously repetitive or have a rhythmic pattern and are Performed without shame or guilt. Patients with this form of NSSI often cannot articulate what's bothering them. It's up to us to effectively biopsychosocially differentially diagnose what's going on. They could have pain somewhere and they're not able to communicate that they could be overwhelmed. The lights could be bothering them. We don't know what's going on, but we need to figure it out in order to address the behavior or eliminate the behavior. With stereotypic NSSI behavior therapy is the primary intervention. Getting a behaviorist involved who can help identify what is triggering what stimuli are triggering the behavior and figuring out how to extinguish the NSSI and develop other alternatives. Compulsive NSSI OCD related behaviors. That's kind of what I want you to think about here. Compulsive and impulsive kind of cross lines some, but we're going to talk just about compulsive here. Severe skin scratching or hair pulling are often compulsive NSSI there's an obsession that they're trying to get rid of and this NSSI is helping to get rid of it. Develop a relapse prevention plan. Rule out intoxication or withdrawal. Sometimes people may engage in some of the severe skin scratching because they think they have bugs crawling under their skin or something. Psychotherapy and medicating or offering making available medication for underlying mental illness. If presentation not everybody's going to want to take meds and that's cool but we do want to make sure that people know when there is an option, that there is an option. Impulsive this is what we've really been talking about for most of this presentation. Your impulsive NSSI are non suicidal self injurious behaviors that are triggered by some form of distress and they're goal directed and, and the goal is to eliminate the distress or the source of the distress. It can include hair pulling, skin cutting, burning, carving, sticking pins or other objects under the skin, interfering with wound healing, picking scabs off and smashing hand or foot bones, among other things. I mean there's just pretty much anything that's done with the intent to hurt the body in order to get relief from social or intrapsychic stress. Develop a safety plan and consider medication for underlying mental illness. Now obviously there's more to treatment. We're going to talk about in a second. Psychotherapy for people with impulsive nssi. DBT Dialectical behavior therapy and act acceptance and commitment therapy have been found to be extremely helpful with this particular population because with dbt, for example, you can do backward chaining from the instance where they engaged in the NSSI and look backwards to see what led up to this. How did you get from getting up this morning and feeling okay to engaging in NSSI at three in the afternoon? What transpired? That helps people identify their vulnerabilities. It helps people identify their reactions. It helps people identify their triggers. Emotional regulation and vulnerability prevention are also really important and integral parts of both DBT and act. Vulnerability prevention vulnerabilities are situations that make you more. Make people more predisposed to have difficulty dealing with life on life's terms. Have more difficulty dealing with the stress when it happens. We've all been there, you know, we've been stressed out over, you know, something or we've been sick or exhausted and something happens. And normally you get a flat tire. Normally getting a flat tire, it would be annoying, but it wouldn't be that big of a deal. But on this particular day, it just kind of, it's more than you can take. It's just more than you can deal with that day. Whatever happened that particular day made you more emotionally vulnerable. Encouraging people to be aware of their vulnerabilities. I've shared with you guys in other classes. Sleep deprivation is a big one for me. If I'm not adequately rested, then mountain or molehills seem like mountains to me. Positive self care will help prevent a lot of vulnerabilities. Good nutrition so the body has the building blocks it needs to make the neurotransmitters. Getting adequate sleep, getting enough vitamin D, going to the doctor regularly to make sure all your hormone levels and vitamin levels are okay. Those are all great places to start. Mindfulness and I use the acronym stop. I encourage people to stop when they start feeling like they're getting, you know, anxious or they don't know how they're feeling. I want them to stop, take a breath, observe what's going on here, what do I need? And then make a plan for how to get that met. And then coping skills training. And this is really an integral part of emotion regulation. You can prevent as much as you can, but life has lemons in it. It's going to hand you lemons sometimes. So people have to have skills to, you know, when things do go awry, have to have skills in order to deal with those. So you can prevent some things, you can mitigate other things. Distress tolerance skills are really important and that is kind of one of the stop skills, I guess. Distress tolerance is helping people accept, identify and accept that they feel distressed and not fight with it, do something different. And Linehan has wonderful acronyms, accepts and improves. You can Google those if you want for helping people remember what to do when they're feeling just angry, enraged, overwhelmed. Any of those dysphoric emotions that feel really powerful, distress tolerance skills helps them do something else for a moment in order to let the adrenaline bleed off, let that HPA axis tamp back down again so they can get into what she calls the wise mind and interpersonal effectiveness skills. You noticed in a lot of these things to get attention for something because you know nobody's listening or to get a reprieve from feelings of being overburdened or too many expectations or whatever. Both of those are things that really relate back to a lack of assertiveness and not being able to say, you know what, that's more than I can handle right now. So interpersonal effectiveness skills are also huge. And another example that we gave the enmeshment in families that interpersonal effectiveness can help people learn how to deal with others in healthy ways and how to start setting boundaries. NSSI is a predictive factor for suicidal behavior in some patients, but not for others. It triples the risk of subsequent, but also concurrent suicidal behavior. Triples the risk. A third variable, and you'll see some links in a minute. A third variable may either mitigate or exacerbate the NSSI to suicide. What are those variables? Well, if the person is plugging along and something really devastating happens and they emotionally dysregulate, but they already had major depressive disorder, that might make them so emotionally overwhelmed that they skip past the nssi, go into that black and white thinking and start seeing the situation as hopeless and move towards suicidal behaviors. They already have suicidal ideation, then, you know, obviously we're going to be a lot more concerned about suicidal behavior. If they have a personality disorder, histrionic, borderline, antisocial, narcissistic, you know, there's a whole list of them, they're at greater risk. So if they already have a personality disorder, it indicates they have some challenges in their flexibility in thinking and are going to potentially be at higher risk for lapsing into suicidal behaviors. MDD stands for major depressive disorder. Substance abuse, especially opiates. And alcohol can be an intervening factor. If somebody is overwhelmed and they engage in NSSI and they're also concurrently using opiates or alcohol, both of which are depressants, opiates can make people feel a little bit better and can also, people can easily overdose on opiates and alcohol, we know, tends to be a disinhibitor. So people are more likely to go from an SSI to something more intense if they're under the influence of substances. Age, as we saw in the statistics, it's obviously much more present or prevalent in adolescents, but you know, up to 26 point something percent of adults also engage in non suicidal self injury and culture. Interestingly, some cultures are pro suicide for some things. If you do something that's going to bring shame on your family, then suicide is seen as an option and sometimes an obligation in certain cultures and not in others. Some cultures believe that suicide is a cardinal sin, for example, and that you will never go to heaven if you commit suicide. So that's not okay. If suicide is an accepted practice in that culture, then it is more likely that a person may move from NSSI to suicidal behaviors. NSSI may be a strategy of emotional adaptation and regulation. If this strategy fails, the adolescent or person must undertake more severe forms of self injury which become progressively closer to suicidal behavior. Just like we see escalation in drug use, if what they're doing now is not getting them the relief that they want that they need, then they may escalate. We see the same thing in nssi. On that line, some people argued in the articles that I was reading that NSSI in some people can become addictive because they become addicted to those natural endorphins that they experience and that sense of control, much like runners become addicted to that runner's high. So tips for treatment take a curious approach to the person's behavior. Instead of going, oh my gosh, okay, tell me about that. One of the first clients I worked with that engaged in self injurious behaviors, you know, she came in, adolescent female and I asked her, okay, you know, tell me more about this, the cutting and tell me what makes you do it, why, why do you do it and what benefit do you get out of it? And she told me, and then we started talking about what other things she had done that helped out a little bit or could help them help her achieve a similar end. You know, the intensity wasn't necessarily the same. And for her there was one particular band that she listened to and putting on her headphones and listening to that band really loudly helped. And I'm like, okay, well it's thinking to myself, not saying it, not great for your eardrums, but it's a whole lot better than cutting. And so I said all right, so would you consider trying that for the next week? And she's like sure. And lo and behold, the next week she came back and she hadn't been 100%. But it did help. On the days that it was, comparatively speaking, a moderate amount of overwhelming distress. The music helped. There were only a couple of days where that didn't work and she just ended up going to the nssi. Looking at that, differentiating, focusing and congratulating and rewarding and highlighting the positive. That is awesome that you know, seven times last week you were able to listen to the music instead of hurting yourself. Remember that these behaviors can communicate some sort of underlying distress. They're not doing it to be mean, they're not doing it to get, get back at you, so to speak. They are terrified or enraged or something. Recovery involves addressing the underlying issues. So for example, if we go back to Fatal Attraction, when Glenn Close got dumped, I think she got dumped or she couldn't have the man she was in love with. Her fears of abandonment were just overwhelming. So she was trying to figure out, how do I make you come back? Because if you don't come back, then I cease to exist. And yes, it's a perfect movie to show people. To demonstrate borderline personality behavior. Assess your own reaction to these behaviors before attempting to engage the person in a conversation about them. Familiarize yourself with self injurious behaviors. Familiarize yourself. Go online. You know, it sounds kind of gory if you will, but go online and look at images in a safe environment. You have to be careful about what you google so you can see what it looks like on the aftermath of somebody who has had extensive engagement, extensive cutting and has extensive scarring. That way when you see it, your eyes don't get as big as baseballs and you're like oh my gosh, you know, recognize it as I look at it as wow, that showed how much you really wanted to live because you did that that many times instead of going the next step and committing suicide. There is a big part of you that really wants to live and there's a big part of you that that is super strong to be able to endure that and has a lot of courage to be able to continue to face life that seems to be on a regular basis untenable. When we're talking about NSSI's and eating disorders. Help the person start to identify other coping skills they may use when they get the urge to engage in the NSSI or the eating disorder. And actually this is true for all of them. Start brainstorming different activities they can do and again, go back to linehan because she did so much wonderful work on self injury and borderline personality disorder. But there are a lot of different things. Holding ice cubes is one of my favorite. Putting your hands in an ice bath if you have that available. There are. We're going to talk about some options here in a minute. Remember that reducing the NSSI or the ED in somebody who's duly diagnosed does not mean the other disorder will be reduced. Dual treatment is essential. So if you're treating the eating disorder, the non suicidal self injury may increase and vice versa. You need to treat both of them. Both of them are behaviors aimed at helping the person moderate their emotions and feel in some sort of control, suppress, repress. So we need to figure out what is causing the person feel so out of control. For families, when you're working with families, teach them about the frames approach, provide feedback. Encourage people to use assertiveness skills and parents to provide genuine, authentic feedback. It breaks my heart when I see you struggling like this. I really want to help you. Responsibility is placed squarely on the person. Nobody can make you change but you. And this is one of the things that a lot of people who engage in nssi, especially NSSI with eating disorders, may struggle with. Other people may want somebody to take care of them, but we need to put the responsibility on them and empower them to make the choice. We can provide advice about different things that might help. We can provide education about, you know, some of the reasons they may be engaging in this behavior and alternatives. If the client is willing, you can consider creating a no harm contract with a menu of options. No harm contracts provide structure and motivation and an emergency list of responses so they can go to it. It provides consequences for sometimes for if they engage in NSSI or a prescribed behavior. If they engage a lot of times with no harm contracts, the agreement is there's no punishment involved with it. If you engage in NSSI during the week, then you are going to call me or you are going to tell me at the next session depending on the client and the severity. The parents can do that too. If you engage in, I want you to tell me. That way I can be aware that you're struggling. Ensure the focus on the contract is development of new behaviors versus elimination of old behaviors. A lot of this is semantics, but it's important. Instead of saying when you got upset this week, how many times did you cut? Or how many times did you self injure? Say when you got upset this week, how many times did you use the new tool, whatever that was, how many times did you hold ice cubes? Empathy is the next part. And the book, let's see, somebody mentioned it back here. Lisa can't remember it right now. But if you encourage parents to read a book about cutting and about self injury to help them understand where the clients are coming from and provide education so you can help them see how this is not an oppositional behavior where the client is just trying to make your life miserable. The client is crying out for help. And if we can help the parents develop empathy then and understand a little bit more about cutting, then number one, they're approaching it from a different perspective. And number two, they're hopefully not going to freak out as much if their kid comes to them and says, you know what, I had a bad night last night and I engaged in nssi. And we want to encourage self efficacy in the client. We want to encourage the client to be able to identify things that work, realize that they can choose alternate behaviors, create win win situations. And this is the list of NSSI behaviors and alternatives. Each client probably has multiple NSSI behaviors they use depending on the setting. When you're at school, you probably can't cut, so they may engage, they may pinch themselves until they bleed, they may pull out eyebrow hairs, whatever it is. Have them list the behaviors that they use and identify alternatives that they could use in that situation. At school you're not going to have ice cubes you can hold. So that's kind of a no good thing to do. But they can do that potentially at home. One client I worked with in identified drawing on herself with a red pen so she wasn't actually bleeding. But if you've ever written on yourself, which you know I do, especially before the mobile phones became prominent, I would write notes on my hand and stuff all the time. It's not real comfortable. And if you write on that tender skin of your wrist, it actually is quite uncomfortable. But she would use that pen and do the same types of motions she would do when she was cutting but she was not cutting. And that would help her for the moment. Was that the end goal? No, but that was a harm reduction behavior. Harm reduction step we took, snap a rubber band on your wrist. People can do this in class. That's one of those things that you can do at work, in class, wherever, listen to loud music, preferably on headphones because a lot of people don't want to hear it. But that can jar people out. Go on a run if you can. If you're at home, if you're again in a place where you can do it drop and do push ups if you've got a private office, more power to you. Wall sits are something that people can do if they're in school or at work. Wall sits is when you back up against the wall and you slide down until you're thighs are parallel to the ground and you hold that. And if you ever had to do that in gym class, you know, it hurts like the dickens. Well, that's one of those things that can help people regroup or refocus for the moment. And that's one of those things you can do in a bathroom stall if you absolutely have to. And I always encourage them to include some sort of support person. Talk to whomever. Most people have somebody that they can confide in. Remember to reward positive progress versus punishing the nssi. So if somebody does it, engages in NSSI but then tells their parent about it, that's progress. If they don't do it as bad as they usually do, that's progress. We want to reward positive progress. Refuse to engage in a fight sometimes, and it really depends on the situation, but sometimes since there is such a power and control struggle, it's important for the parent to say, okay, I hear what you're saying and instead of fighting with you, I'm gonna let you, you know, get all your stuff out, get all your emotions out and I'm gonna be here and I'm a safe place that you can let loose on if you will. Encourage families as a whole to learn how to communicate assertively and openly about how they're feeling, what they're needing and what feels uncomfortable without getting, you know, into huge blow ups. And everybody needs to practice self care. NSSI is a common issue to see in all age groups, but is more common in adolescents. It usually represents a way of dealing with the stress the best way the person knows how. They're just, they're out of options and they want to live, they want to survive, but they can't bear the pain at the moment. Treatment involves identifying the triggers for the NSSI and developing skills and resources to help the person mitigate or or eliminate the distress caused by the situation. Functions of the NSSI and developing alternate behaviors that meet the same need. We need to look at balancing energy. For example, when they get angry, they may want to lash out. So what alternate behaviors can they use when they need support but they don't feel like they're getting it and they feel like injury is the only way to get people to pay attention? How can they develop assertive communication skills? How can they get their support that they need? How can they feel in control and empowered if they're Alex Thymec? How can they feel something? And how can they get relief from demands from parents, from school leaders, from life itself if they need to? A couple of books that y' all brought up and I want to share in here, Stopping the Pain, a Workbook for Teens who Cut and Self Injure and Helping Teens who Cut by Hollander, were two resources that were brought up by the people in the chat room. Oh, and Inside A Cutter's Understanding and Helping those who Self Injure by Joshua Clark. Alrighty everybody, we will be turning our attention to trauma on Thursday and the psychosocial impact of trauma, and I will see you then. Your name and your license number will be on your certificate as you put it in your profile on all CEUs. So make sure to Let me see. This is the link that was sent to you in your welcome email that has a video on how to update your profile if you're not sure how to do that. Alrighty everybody, have a wonderful day. 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