Research Based Practice
Assessment and Intervention for Students Who Self–Injure
By Crystal Carroll, Heather Olwig, & Melissa Vasquez
When students reach adolescence, they have often been known to devise destructive outlets for their self-expression (e.g., suggestive dress, tattoos, piercing, and sexual risk-taking). Recently growing in popularity, to almost epidemic proportions in the general adolescent population, is the act of selfinjury. Self-injury refers to the intentional self-infliction of wounds by cutting, burning, or otherwise wounding of the skin without the intent to die (Walsh, 2006).
Such behaviors are becoming an increasingly prevalent phenomenon and are plaguing teens, parents, and schools. A study by Olfson, Geameroff, Marcus, Greenbers, and Shaffer (2005) noted that self-injury incidence reports increased among patients in community hospitals between 1990 and 2000 from 4.3% to 13.2%. Furthermore, the incidence among adolescent inpatients has been cited at an alarming 40% (Hurry, 2000). The cause for the increase in self-injury reports is unclear. Some speculate that the increase in incidence rates is due to more individuals self-harming to relieve stress. In a study conducted of patients who exhibited self-injurious behavior, Van der Kolk, Perry, and Herman (1991) found that exposure to physical or sexual abuse, physical or emotional neglect, and chaotic family conditions were reliable predictors of both the amount and severity of cutting. Their research also suggests that while childhood trauma contributes heavily to the initiation of self-destructive behavior, a lack of secure attachments can serve to maintain the behavior.
A commonly supported theory behind the motivation of self-injury is that the person believes this behavior will help achieve emotional equilibrium (Lukomski & Folmer, 2006). An adolescent who self-injures often does so when unable to regulate or control his/her emotions. The act of self-injury can serve as a means for such adolescents to relieve intolerable emotional pain, and is almost always a means of communicating a deep sense of anguish. Studies have suggested that when people who self-injure get emotionally overwhelmed, an act of selfinjury brings their levels of psychological and physiological tension and arousal back to a bearable state (Focus Adolescent Services, 2000). While such behavior is clearly a sign of a troubled individual, it is usually not driven by suicidal intentions, but rather constitutes a cry for help. However, most teens who engage in self-injury make considerable attempts to hide their wounds and scars.
To effectively help adolescents who engage in self-injurious behavior, school professionals working with them must understand what a powerful role coping mechanisms play. While there has been limited research conducted on the effectiveness of treatment for adolescents who self-injure, the interventions that have been found to be the most effective in reducing symptoms have generally involved the combination of cognitive behavioral therapy and medication for underlying disorders. Additionally, the “contagious” effects among peer groups demand that professionals working with self-injurious individuals be aware of the causes and signs of the behavior and establish appropriate procedures to respond to students who self-injure in order to minimize the possibility that students who self-injure will influence other students to do the same.
Self-injury has become significantly more pervasive in the general adolescent population and has possible implications for students' academic well-being. The educational environment has emerged as the leading place in which adolescents who self-injure are identified. Therefore, the school is the place where the provision of treatments can often begin. It is important for individuals working in such settings to gain a thorough working understanding of the nature, meaning, and function of self-injurious behavior
The key target of assessing students who self-injure is “finding the specific source of the unendurable, inescapable pain” (Walsh, 2006, p. 16). It is important for the assessor to uncover the specific problem(s) that is/are leading the individual to partake in self-injurious behavior. Assessment of self-injurers should be multimodel and evaluate a variety of individual and environmental factors. This assessment would include assessing their physical and mental health, their cognitions, emotional regulation, behaviors, family history, cultural values, and peer relationships (Walsh, 2006).
Interviews are an important assessment method when working with students who self-injure. They are valuable in the beginning of evaluations to formulate hypothesizes as well as throughout the evaluation to clarify ambiguous issues. Some important themes to investigate through interviewing include the intent of the act, the level of physical damage and potential lethality, the chronicity of the harming behavior, the methods used to injure, the level of psychological pain, feelings of hopelessness and helplessness, and the level of decrease in discomfort following the injury (Walsh, 2006).
Other assessments that have been useful in identifying underlying issues that the individual may be experiencing include various standardized self-report measures. Self-report measures can serve as initial assessments as well as assessments used after treatment to identify change. Specific assessments that have been found to be useful include self-reports that assess levels of depression or anxiety.
In addition to an interview and self-report measures, conducting a comprehensive social history of the individual's and family's mental health, parenting practices, home environment, medication, and possible traumatic life events will provide background information and insight into the underlying issues surrounding the self-injurious behavior. This information can be collected through interviews with family members and the student, medical records, and previous evaluation reports.
When the assessment information is collected, it is also important to collect baseline data of the self-injury behavior. Baseline data consists of identifying the number of wounds, patterns or symbols used, tools used, and the physical location of the selfinjurious behaviors. In addition, information should be collected regarding how often the student is self-injuring, and what the antecedents and consequences are for the behavior. Having adequate baseline data on specific behaviors prior to treatment will inform the target of the intervention and provide an initial point of comparison for the student's progress during the intervention.
The intervention strategies suggested for students who self-injure are offered to develop an understanding of self-injury and to provide a structure for teaching self-injurious adolescents how to cope with self-injury. The following strategies are researchbased approaches, but may need to be adapted to meet the individual student's needs. It is important that sessions with the adolescents include modeling (i.e., professional explanation and modeling of behavior), guided practice (i.e., student practice with frequent professional feedback), and self-control (i.e., student practice with minimal professional feedback). School professionals should receive training in evidence-based therapeutic interventions and should collaborate with other school personnel as well as therapists that the student is receiving treatment from outside of school. Additionally, it may be important for the school professional to coordinate with the student's physician if the student is taking medication.
First steps. Oftentimes, successful early treatment is largely dependent upon the recognition and articulation of the student's underlying conflicts. The first step in responding to an adolescent engaging in self-injuring behavior is to express appreciation and concern for their obvious pain and anguish (Walsh, 2006). The more the student is able to trust the school professional, the more leverage the school professional has to actually be helpful. Because of the shame students might feel about their self-injury, or because they may fear the consequences of discussing their behavior, it is necessary that the school professional be informal and dispassionate—neither overly solicitous and nurturing nor judgmental or condemning. Careful explanation of the therapeutic process, defining consequences and outcomes, can help in gaining the trust of the student. The rules of confidentiality need to be clearly outlined and defined for the student.
Plan for safety. After collecting detailed baseline data, a plan regarding self-injurious behavior should be constructed (Walsh, 2006). Assist the student in preparing a plan, implementing the plan, and monitoring the usefulness of the plan. Explain the importance of making a plan to help reduce their self-injurious behavior. Ask the student for possible hypothetical situations or possible thoughts they might have when they self-injure. Use those situations or thoughts to guide writing the plan. Allow the student to change the plan as they progress through the intervention and find out what works and what does not work. When writing the plan, expose the student to evidence-based strategies for reducing self-injury behaviors. Have the student decide what strategies appear to be interesting and useful. Discuss when the strategies may be used depending on the place or situation the student may be in. The plan should have clearly stated measurable goals. It should also specify any rewards to be obtained. Caution should be taken to ensure that the student is not asked to give up the behavior before they are ready, unless the behavior involves extensive tissue damage or is a threat to their life. Important in the plan is a contract that includes a statement that fosters full disclosure between the student and the school professional as well as a statement regarding confidentiality terms during intervention.
Logging behavior. It is beneficial to teach the student to self-monitor their self-injurious behavior (Walsh, 2006). Train the student to accurately report the number of wounds, patterns or symbols, use of a tool, and physical location of the self-injurious behaviors. Also, teach them to report how often they are self-injuring, and what the antecedents and consequences are for their behavior. The student should log each self-injury incident. Once the student begins to use treatment strategies, the student can log replacement strategies used to replace the self-injury behaviors. This will help the student identify the strategies that work best for them. Frequent recording by the student and consistent evaluation by the school professional also helps to evaluate the primary elements that precipitate episodes of self-injury, build the student's awareness of their self-harming behavior, and ultimately evaluate the effectiveness of the intervention.
Diversion techniques. The purpose of diversion techniques is to deflect attention from thoughts, plans, and urges to self-injure (Walsh, 2006). Have the student brainstorm activities they can do to distract themselves from self-injuring. Some examples are watching TV, petting a cat, grooming a dog, playing solitaire, cleaning the house, playing video games, washing the car, making brownies, or reading a book.
Negative replacement behaviors. Teaching replacement skills and behaviors is paramount in the treatment of self-injury. Replacement behaviors are behaviors that include tactile, visual, and auditory options. Identifying a set of skills and practicing them early in treatment can help to enable the client to use the skills at other times when emotional distress is high (Walsh, 2006). It is important for students who self-injure to acquire skills that manage their emotional distress as effectively as self-harm behaviors do in order for the student to overcome the act of self-injury. While no individual should depend on negative replacement behavior exclusively, negative replacement behaviors can serve an important transitional function. The use of negative replacement behaviors operates under the assumption that the act of self-injury is symbolically represented but that no tissue damage is inflicted. Have the student brainstorm some ideas of replacement behaviors. Examples of negative replacement behaviors include marking one's body with a red-colored marker rather than cutting or burning, applying topical stimulants to a body area previously self-injured, snapping a rubber band on areas previously self-injured, applying a temporary tattoo and scratching it off, gently stroking a body area with a soft cosmetics brush or other soft implement, drawing a picture depicting a self-injury of a body area, writing about the act of selfinjuring, or dictating a self-injury sequence into a recording device.
Physical exercise. Physical activity can be used as a replacement activity. Exercise can elicit an adrenaline rush that often is obtained from a self-injurious episode and provides a feeling of release for the student (Walsh, 2006). Some examples of beneficial exercise are walking, running, playing basketball, swimming, roller blading, martial arts, and lifting weights. It is important that the preferred mode of exercise be accessible when the student becomes distressed, but it is also important to set a schedule for consistent activity. Develop an activity plan that depicts ways the student can exercise, schedule specific times during the day to exercise, and set the duration of the activity.
Mindful breathing skills. Mindfulness refers to being calm and relaxed while also being fully alert. Learning mindfulness is a good match for self-injurers because they experience the opposite of mindfulness so frequently (Walsh, 2006). This replacement skill is one of the most beneficial. Teach the student to practice conscious breathing, which allows thinking to slow down and offers a feeling of restfulness. These activities are recommended because they are easy to learn, they enable individuals to physically calm themselves by reducing heart and respiration rates, they can be practiced and used at almost any time, there is no cost or need for equipment, there are no side effects, no assistance from others is required, and they can produce quick results. The recommended length of mindful breathing is 15–20 minutes at least 3 times a week. It is important to monitor the frequency and length of practice, the physical location, and the results obtained.
Visualization techniques. Visualization is a replacement behavior and involves identifying pleasant, relaxing scenes and retrieving them as a self-soothing strategy (Walsh, 2006). Some people find that visualization helps to calm them down. There are two main types of visualization. Reality-based visualization is when the student visualizes a scene that is found in the student's current environment. Fantasy-based visualization occurs when the student visualizes scenes that are fictional and imaginary. The school professional models the visualization activities with the student, provides guided practice, and feedback.
Artistic expression. Using art to express day-to-day experiences can be beneficial for self-injurers. If the student can begin to write, draw, paint, or sing about the emotions that lead to self-injurious behavior, it is a step in moving toward expressing discomfort rather than acting on it (Walsh, 2006). Another artistic activity is a 'Success Journal,” in which the student writes about his or her successes and accomplishments. The intent is to direct the student away from thinking pessimistically about himself or herself, the world, and the future, and to celebrate positive events. Artistic expression can be used as a distraction until the intense urges to self-injure pass. The psychologist may want to have a variety of art materials in the office to practice the skill with the student. Music is a key replacement for many students. Students can learn to listen to music mindfully by focusing intensively on melody, specific instruments, dynamics, cadence, vocals, beat, harmony, and so forth.
Cognitive restructuring. Cognitive restructuring consists of teaching the student to identify the antecedent factors that lead to maladaptive beliefs, cognitive distortions, and the self-injurious behavior and train the student to think flexibly about the situations (Walsh, 2006). Train the student to identify (a) the trigger (i.e., a thought/ situation that results in the person feeling uncomfortable), (b) interpretations of the thought/situation (i.e., the process of thinking about what has happened to the student and deciding what it means), (c) emotional reaction to the thought/situation (i.e., what the student feels after interpreting a thought/situation or trigger), (d) the decision made (i.e., making a choice about the action to take), (e) behavior (i.e., acting out the decision made), and (f ), the consequence (i.e., the direct result of the behavior). Once he or she is able to identify the trigger and the reaction to it, help the student to rephrase maladaptive thoughts and increase flexibility in thinking. Discuss how flexible thinking changes feelings and how there are multiple meanings (both positive and negative) for situations. Train the student to think flexibly and to make positive decisions in stressful situations that would otherwise lead to self-injurious behaviors.
Family treatment. Many treatments provided outside of the school for students who self-injure will employ family treatment along with individual treatment. Families can also be incorporated into services that the student is receiving at school to help facilitate the maintenance of success the student has made. Family treatment should only be done under the request or permission of the student. If the family is severely troubled, consult with the student's outside therapist or refer the family to a family treatment facility. Here it is important for the school professional to guide the student in how to instruct his or her family about the facts of self-injury and what it means, as well as what he or she has learned to help stop self-harming. Family members can be very effective in encouraging the student to use these skills outside of school, if they are made aware of how the skill is used, and during which situations it is particularly effective for the student.
Ethical and Legal Issues
School psychologists are ethically obligated to keep student-reported information confidential unless disclosure is required to prevent clear and imminent danger to the student or others (Jacob & Hartshorne, 2003, p. 324). The issue of confidentially can get very complicated with students who self-injure. Self-injury may be interpreted as a suicidal action by school psychologists, thus making reporting self-injury mandatory. However, research supports the idea that self-injury is a coping strategy, and not a suicidal action (Kress, Drouhard, & Costin, 2006). A thorough suicide assessment and self-injury assessment will help the school psychologist determine if the student is in imminent danger, assess for any additional risk-management issues, and ultimately determine what actions should be taken regarding reporting.
School psychologists are in a unique position: Not only do they have responsibilities to students, but they also have responsibilities to parents and the school (Kress, Drouhard, & Costin, 2006). The school psychologist must consider at what point parents and administrators have the right to demand access to confidential information. At the same time, a school psychologist cannot treat a student who self-injures without getting consent from the parent or legal guardian. In a school setting, it can be very difficult to balance the confidentially rights of minors, the psychologist's responsibilities to act in the minor's interest, and the legitimate rights and concerns of the parents and the school.
With an increase in prevalence of self-injurious behavior in the adolescent population, it is important that school psychologists recognize the signs and symptoms of self-injury and have the knowledge needed to appropriately intervene (Kress, Gibson, & Reynolds, 2004). An ethical standard for school psychologists set by APA and NASP states that the professional school psychologist functions within the boundaries of individual professional competence and accepts responsibility for the consequences of his or her actions. School psychologists are only to practice within the boundaries of their competence, based on education, training, and experience. To work with students who self-injure, it is required that school psychologists are educated on the etiology and functions of self-injury, as well as appropriate interventions (Kress, Drouhard, & Costin, 2006; White, McCormick, & Kelly, 2003). School psychologists have an ethical responsibility to assess whether they have the knowledge and skills to help students who self-injure.
Crystal Carroll, NCSP, is a school psychologist in Canyons School District in Sandy, Utah. Heather Olwig, NCSP, is a school psychologist in Madison, Wisconsin. Melissa Vasquez is a school psychologist with the Bristol No. 1 and Twin Lakes No 4 school districts in Wisconsin.
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