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Treating Self-injurious and suicidal behaviors in residential settings.

This brief article focuses on aspects of prevention, assessment, and treatment of self-injurious behavior (SIB) in residential settings. From the outset, it is important to note two things. First, the authors believe that a contextual view of SIB is critical to successfully addressing these issues. A contextual view identifies the confluence of an individual's learning history, immediate situational factors, environmental cues, and anticipated outcomes as key predictors of self-injurious behavior or suicide attempts. Second, they note that it is impossible to learn and master all that one needs to know from one short article; those who find this presentation compelling are encouraged to seek out further training and supervision in the approaches discussed here. For the purposes of this article, the term residential settings will refer to any inpatient psychiatric or forensic/correctional setting with a moderate to extended length of stay (thirty days or more).

Preventing Self-Injury and Suicidal Behaviors

Self-injury and suicide attempts may occur in individuals displaying symptoms consistent with a variety of Axis I or Axis II disorders. Many individuals with serious mental health disorders will never attempt SIB, whereas individuals who have never displayed symptoms warranting a psychiatric diagnosis will successfully commit suicide, seemingly out of the blue. Research consistently shows that past SIB is the best predictor of future SIB and of suicide in and out of residential placement or custody. The presence of suicidal ideation is linked to overall higher levels of dysfunction and psychopathology in and out of custody (Ivanoff, 1989; Linehan, 1981, 1997a). In custody, higher levels of suicidal ideation are found among those engaging in self-harm than among those outside of custody, and individuals who commit suicide in custody are even more likely to have engaged in previous SIB than those in the community (Dear, Thomson, Hall, & Howells, 1998; Dear, Thomson, & Hills, 2000). Thus, there is a clear link between self-injurious behavior and completed suicide.

Treatment Targets

Given the above, preventing and treating all self-injurious behavior, not just suicide, should be the focus in residential settings (see Schmidt & Ivanoff, 2007). The prevalence of nonlethal SIB in the general population is greater than the prevalence of suicide, with self-reports among general population samples indicating that between 15 to 20 percent of young adult or adolescent respondents have engaged in self-injurious or suicidal behavior in their lifetime (Muehlenkamp & Gutierrez, 2004; Whitlock, Eckinrode, & Silverman, 2006). Among ten- to twenty-four-year-olds in the U.S., suicide is the third leading cause of death, with numbers far higher than those for any disease process (National Center for Health Statistics, 2012).

No data suggest that clinical interviews or skills can allow clinicians to successfully predict which of their clients will kill themselves and which will not. Attempts by researchers to distinguish these populations based on psychological measures have similarly failed (e.g., Muehlenkamp & Gutierrez, 2004). Nonetheless, it is not uncommon to hear residential staff and clinicians identify residents as either suicidal or manipulative (the latter implying a low risk of serious injury or death). Attempts to distinguish manipulations from real suicide attempts distract staff unnecessarily, with potentially deadly outcomes.

Although some clinicians argue that the phenomena are distinct and separate, the evidence does not support this stance from a prevention, assessment, or treatment standpoint. Individuals often engage in both types of behavior for a variety of reasons (Ivanoff & Hayes, 2001; James, Stewart, & Bowers, 2012); a contextual worldview notes that SIB may serve many functions. Further, many individuals without the goal of ending up dead use potentially lethal means (Brown, Comtois, & Linehan, 2002 Dear, Slattery, & Hillan, 2001) and experience instances where they harm themselves more seriously than intended (Whitlock et al., 2006). A study by Brown and colleagues (2002) of seventy-five female self-injurers found that only 25 percent identified their most recent self-injury as unambiguously suicidal. In the same study more than half of the subjects had engaged in separate events of SIB within the past year, some with intent to die and some with no intent to die. Access to means of self-harm or suicide may also influence the method and potential lethality of an SIB event, with the relative paucity of self-harm means in many custodial settings leading to a more lethal method (e.g., hanging) than the individual might choose in a community setting.

Using labels such as gesture and manipulative to describe SIB may also falsely modify expectations of future SIB behavior, potentially decreasing staff responsiveness and quality of care. Staff assess, plan, and communicate most effectively when they provide clear behavioral descriptions rather than interpretations of behavior. Avoiding interpretive labels is consistent with the advice of leading suicidologists (Farberow & Schneidman, 1961; Linehan, 1993a), emergency psychiatric guidelines (Butcher & Maudal, 1976; Thienhaus & Piasecki, 1997; Thienhaus, 2007), and research on suicidal behaviors in forensic settings (Dear, 2006; Toch, 1975). Thus, the authors recommend that all intentional self-harm and suicidal behavior be given top clinical priority in residential settings. Fortunately, it is possible to successfully assess and treat both behaviors, as outlined below.

Screening

Brief screens are generally used at initial intake to residential centers to identify residents at risk of future SIB or suicidal behavior. Admission to psychiatric inpatient care significantly increases suicide risk, and the first week of admission is the most critical, as one-quarter of in-patients suicides occur during this time (Hunt et al., 2012). Derived from population-based risk factors, screens statistically identify demographic variables that may place the individual at increased risk upon entry to the residential centers. However, this knowledge of static risk factors such as race, gender, age, employment, or marital status has limited predictive utility.

As noted above, although inclusion in a group with elevated risk (e.g., under psychiatric care or incarcerated) is of interest, the best predictive variable for future behavior is whether an individual has ever actually done anything to hurt or to try to kill himself or herself in the past. The history, presence, and frequency of nonsuicidal self-injury (NSSI) episodes are significantly related to the presence and number of suicide attempts, more so than to depressive symptoms, hopelessness, and other common factors (Andover & Gibb, 2010). Screening tools should contain this question along with questions about other risk and protective factors. It is important to note that almost all psychiatric inpatient and all forensic clients demonstrate high suicide risk when evaluated using general population-based risk screens (Gratz, 2003). Few screens are validated to discriminate among forensic clients at increased risk. Positive endorsement on screening tools requires further assessment and follow-up.

Assessing Risk and Protective Factors

Positive screens for suicide risk should be followed by individualized assessment to determine the specific risk characteristics. Specifically, what are the individual, environmental, and interpersonal factors linked to risk characteristics for this resident? The essential task here is to conduct a thorough assessment (interview, records review, and family interview if possible) to establish whether the resident is, in fact, not at risk for SIB. Given the high impact of a completed suicide in residential settings (Hayes, 1995; Ivanoff & Schmidt, 2006) and the increased risk overall for custodial populations, assessment of those who screen as high risk for SIB should be a rule out process; residents do not need to prove they need treatment for SIB, but rather they must prove that they do not! There are four characteristics associated with imminent risk of action:

* history of SIB during the past year, particularly if associated with suicidal intent;

* current ideation;

* current threats (or other communication of intent);

* planning or a completed plan (Linehan, 1997a).

A history or presence of any of these imminent risk factors should lead to the individual being placed on heightened supervision status while further assessment and possibly treatment is carried out. The next level of assessment involves a thorough history of such behavior (onset, frequency, intensity, and duration) as well as a behavioral or functional analysis, a comprehensive description of internal and external events surrounding an individual SIB event (ideation, communication, or act; Ivanoff & Schmidt, 2010; Linehan, 1993a; Schmidt & Ivanoff, 2007). The behavioral analysis is based on learning theories of behavior and examines the structure around the antecedents-behavior-consequences of a given SIB. Treatment of an individual at high risk for SIB or suicide would typically involve a behavioral analysis of several incidents--enough to get a thorough understanding of the situations that likely lead to strong urges or acts. Some individuals will report only high ideation; others may have dozens or hundreds of self-harm acts and persistent ideation. The clinician's job is to understand each client's risk profile in order to treat the behavior, and to provide information to line staff in order to keep the resident safe.

The behavioral analysis is a critical assessment tool used to determine the functions and other controlling variables of a behavior targeted for treatment. Importantly, it provides a contextual and client-specific understanding of the individual's behavior, provides clear targets for treatment intervention, and allows for evaluation of improvement in risk as treatment progresses. It is a core element of one of the most researched successful interventions for suicidal behavior, Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b), and a variety of other contextual psychotherapies currently in practice.

No Self-Harm Commitment

Upon entry, all residents should be asked to commit to not self-harm and to talk to staff if they are thinking about or having urges to do so. Eliciting a no self-harm commitment is one of the primary strategies and programmatic elements in treating SIB (Linehan, 1993a). It is important to note that there is no empirical support for the use of such commitments solely to prevent future SIB, and the authors advocate their use only in conjunction with active ongoing cognitive-behavioral treatment to reduce risk (Rudd, Mandrusiak, & Joiner, 2006). A commitment to not self-harm is a clinical entry point for treatment and a touchstone to return to in ongoing work. "I'm no longer committed" on the part of the resident is treated as a problem to be solved, not a moral failing or the end of treatment. Such reversal decisions are often emotionally driven, indicative of mood-dependent habits or an inability to tolerate negative emotional states (Marlatt & Gordon, 1985).

Pros and cons is a standard decision-making strategy for evaluating alternative solutions in a given situation or life circumstance (e.g., decisional balance in motivational interviewing; Miller & Rollnick, 2003). The authors recommend its use as a commitment method to identify first the client's perceived pros for committing to reducing SIB and then the cons. Using four squares, resident and staff list pros and cons for committing to reducing SIB and then pros and cons for not committing to reducing SIB (Linehan, 1993a). This is followed by the question "Which option seems most consistent with your values and long-term goals?" Identifying a client's reasons for not killing himself or herself is also a potent measure of risk (Ivanoff, Jang, Smyth, & Linehan, 1994) as well as a source of information about protective factors for the clinician treating the individual. Risk assessment and the resident's willingness to commit should then guide staff decisions on suicide precaution measures.

Responding to SIB and Suicidal Behavior

In no case should suicidal or self-harm behavior be ignored, downplayed, or written off as attention getting or manipulative. Regular monitoring during the course of the day and night should be established upon entry to a new residential setting for clients with a positive history of self-injury, along with programming in an open or public area when possible (Daniel, 2006). Guidelines for treatment of mentally ill offenders discourage the use of isolation. Even residents who admit low intent to act during previous threats to kill themselves should be placed on some increased monitoring schedule while the past behavior is assessed and coping strategies or skills for tolerating similar cues are observed or taught (if not already present). Previous statements of suicidal intent confer increased suicide risk (Linehan, 1997a), but not following through on previous statements does not preclude action in the future. Simply ignoring clients with a history of suicidal communication (i.e., placing the behavior on an extinction schedule, or nonreinforcement leading to elimination of the behavior) may lead to increasing intensity of client urges and action (i.e., an extinction burst), significantly increasing the risk of injury or death.

Information regarding past SIB, current problem solving, and skill demonstration should be documented on an ongoing basis in the unit log, case files, and treatment plan. Although this may seem time-consuming, the best response to clients with SIB is one that monitors and keeps the resident safe without reinforcing or escalating the resident's behavior--a delicate balance. The goal of treatment is to reduce the client's risk over time, and thus the need for such intensive monitoring.

Get Over Feeling Manipulated and Taken In

The staff in residential centers generally make great efforts to avoid being taken in by manipulative residents, feeling the need to consistently be one step ahead of the residents and in control. It is best to expect that residents will treat clinical and custodial staff exactly as they have treated others in the past (i.e., they will not always tell the truth). Ignoring self-injury communication to avoid being played is an understandable response, but it may have disastrous consequences. Instead, the use of effective contingency management, including sometimes extending or taking clients more seriously than they intend (Linehan, 1993a) is both effective treatment and supportive of a safe and secure environment in residential settings. Ensuring that staff have effective tools to deal with concerns of being played is a necessity, as is effectively addressing untruthful communication.

The SIB Protocol

Residential centers should have a dependable set of consequences (i.e., a contingency management program) for residents who engage in suicidal or self-harm acts. These interventions have multiple goals:

* to immediately block imminent or further SIB and suicidal behavior

* to address possible reinforcing quality of outcomes

* to increase behaviors that will prolong life (i.e., to teach and reinforce alternate actions)

Following any SIB act (e.g., scratching, cutting, burning, poisoning, or asphyxiation), the resident is medically assessed and treated, is placed under some level of increased supervision, and is restricted from access to implements or methods of self-harm.

Enhanced observation of residents is a demanding and often boring task frequently relegated to the least skilled or even to per diem staff. This can be a mistake. Ensure that staff employed for one-on-one monitoring are trained in how to observe residents without engagement, limiting discussions to completion of treatment assignments or coaching to identify skills the resident can use now to tolerate distress or improve the situation. Being on suicide watch at any level should not be considered advantageous by residents, so heart-to-heart talks, oneon-one time playing cards, and watching movies/TV with staff, etc., are strongly discouraged.

Following an act of SIB, the resident works on the behavioral analysis, a written report of the SIB. This should be done in a common area under observation or in a highly visible room or area. Isolation is not recommended unless the client is clearly a threat to self or others in a less restricted area. Generally all other social activities and communication with peers stop for this resident until a detailed, exhaustive behavioral analysis is completed and reviewed by staff. Line staff interactions engage the resident in recommitting to treatment and safety, reinforce the client's hopeful statements and realistic future problem solving, and assist in the completion of the behavioral analysis or in identifying skills that could have been used to avoid the SIB; other conversations should be held to a minimum. The primary focus should be reducing future SIB. This is also consistent with Linehan (1993a), who advocates a twenty-four-hour rule of no contact with the client's primary counselor, which has been adapted for residential programs (McCann, Ivanoff, Schmidt, & Beach, 2007). The twenty-four-hour rule was devised in part to address the potentially reinforcing effect of debriefing the event with a caring individual--the client's case manager or counselor. Residents with a history of SIB should be coached to seek assistance from staff before harming themselves, not consolation or forgiveness afterward (cf. Linehan, 1993a).

The response to a client making verbal or written statements communicating intent to self-harm or a desire to be dead should always involve an assessment of imminent risk (commitment to safety, plan to self-harm, means to carry out plan) and whether an act has recently occurred. Typically, the completion of a behavioral analysis and treatment planning will follow such a communication: Risk for action is heightened among those who threaten to self-harm. The decision about whether to increase observation of the client and restrict access to potential self-harm means should be based on perceived level of imminent risk.

Validation (Linehan, 1993a, 1997b) is another clinically useful strategy in working with clients who are at risk for SIB. Validation identifies the kernel of truth in the client's reaction and communicates to the client that aspects of his or her thoughts, feelings, beliefs, and behavior may be understandable. When discussing SIB with a resident, the staff member might say, "Given how miserable you were when you got that news, I can see how you'd think back to past times when you cut yourself and felt better," or "I can understand that you think that killing yourself will end your pain." These statements are not the same as conveying approval. Hurting or killing oneself does not make sense; however, the urge or desire to do it may make sense from the client's perspective. Validation provides one of many engagement strategies useful for working with clients who may be reluctant to talk about their own SIB actions or urges. Further, it is consistent with the contextual approach to assessment and treatment; all behavior makes sense given the client's learning history, beliefs, environmental cues, and contingencies.

Treating Self-Injurious and Suicidal Behavior

The elements of contingency management, engaging and motivating clients, and coaching and skill training identified above in the immediate response to SIB are all aspects of a comprehensive and effective cognitive-behavioral approach. The behavioral analysis is the primary assessment tool, allowing the client and treatment provider to identify variables controlling the target behavior (SIB). It is used to develop an individualized treatment plan that addresses idiographic risk factors for further SIB. Active client collaboration is required, as an accurate report of the events before and after the action allows for hypotheses about what is cueing and possibly reinforcing the behavior, as well as other client-specific risk variables (e.g., client-specific beliefs about self-harm and how others will respond). As treatment progresses, the client's demonstration of new or strengthened protective factors related to these risk variables informs and supports the decisions to reduce behavioral restrictions and frequency of observation in a step-wise fashion (Ivanoff & Schmidt, 2010).

Forming Clinical Hypotheses

The function of SIB can be thought of as the expected outcome or consequence of maintaining the behavior. Identify this by asking "What problem did this behavior solve?" or "What outcomes did the resident hope to achieve from the SIB?" Keep in mind that a given action may serve multiple functions or solve multiple problems. For instance, cutting one's arm can bring nearly instant relief from high levels of emotional distress. It may also reduce isolation through concern expressed by friends and family Demands placed on the individual may also be reduced, providing relief from unwanted activities or responsibilities. Well-meaning efforts by caring individuals may inadvertently increase the likelihood of the behavior occurring again. Also keep in mind that these functions may be totally outside the client's awareness.

Questions that help identify critical cues or other influential variables include "What is the best predictor of this behavior occurring again?" and "What, if changed, would most strongly decrease the likelihood this behavior will occur again?" Examples of cues may be the loss of a significant relationship or finding out that one will not be able to return home following discharge. A significant risk factor for self-harm might be viewing SIB as a reasonable way to deal with emotional pain or believing that a boyfriend will not break up if faced with a threat of suicide. These factors need to be identified for each individual and addressed directly as part of the treatment.

Whereas most SIB can clearly be linked to outcomes, such as attempting to reduce distress, for some individuals a specific cue may be so dysregulating (and the resident so unskilled at coping with the cue) that alternatives to killing or harming oneself are not even contemplated. (A notable exception is SIB associated with frontal lobe dysfunction or psychosis. This behavior is likely controlled more by the disease process than by outcomes. Here, appropriate consultation should be sought and management of the SIB will focus heavily on structuring the environment, for example, by blocking access to methods during psychotic episodes or psychopharmacological interventions to abate symptoms. For more information, refer to "Understanding and Treating Self-Injurious Behavior" (Edelson, n.d.).

The first twenty-four hours of incarceration is a particularly high-risk period for completed suicide: Being locked up initially may be a cue that elicits extreme shame, fears of being raped or beaten while in prison, or a reminder of serious sanctions that are sure to follow (e.g., a spouse leaving, a judge applying a suspended sentence, loss of a job or a place to live). Each of these scenarios may elicit a feeling of crushing hopelessness that the client feels unable to tolerate or survive. In other circumstances, SIB may be overlearned (habitual) or powerfully responsive to a given cue such that the client may not even be aware of the steps leading to SIB once a cue is presented (e.g., a client with post-traumatic stress disorder is re-traumatized during a strip-search, dissociates, and is unaware of placing a shirt around his neck once he is in his room). In these instances, responding to the cue needs to be targeted as a critical element of the treatment plan. Briefly, the response to cue-driven behavior should focus on identifying the cue, seeking ways to avoid or reduce the frequency of the cue (if possible), applying distress tolerance skills (Linehan, 1993b) to cope with the immediate response to the situation, and identifying response solutions that favor valued long-term outcomes (rather than short-term avoidance outcomes). Treatment can also work to reduce the aversiveness of the event eliciting the SIB (via exposure or cognitive restructuring/defusion).

Clearly, motivation of the client at all stages of this work will be critical, and the use of validation, cheerleading, a measured approach, and other supportive strategies will be necessary For example, a resident hearing voices telling her to kill herself may benefit from a medication trial in addition to a validating and encouraging environment while learning skills to tolerate the voices or to manage situations that trigger the voices.

Developing Replacement Behaviors and Skills: Skills Modules and Treatment Targets

Skills can be used to address critical variables identified in the behavioral analysis or other assessment: vulnerabilities, cues, and behavioral responses. Skills are also used as replacement behaviors, helping the resident to attain the same or similar goals sought through the target behavior (SIB); once learned, they are functional equivalents to the SIB. Thus, a resident seeking social support may be taught other skills to attract and hold the interest and attention of those around him or her. A comprehensive skill set found to be effective at reducing self-injurious and suicidal behaviors is that developed in DBT (Linehan, 1993b), which has a growing research base involving clients with a variety of complex disorders (borderline personality disorder, substance dependence, depression, posttraumatic stress disorder, bulimia, etc.). These skills target the dysregulated emotional style of many self-injuring residents in custody. Preliminary applications in adult and juvenile forensic residential settings, as well as community-based inpatient facilities, suggest a broad-based utility with residential populations (McCann, Ball, & Ivanoff, 2000; Trupin, Stewart, Beach, & Boesky, 2002). The four skills modules--mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance--are well-tolerated and successfully applied in forensic settings (McCann et al., 2007).

After SIB: Evaluating the Risk of Future SIB

How is the decision made to reduce or eliminate extra supervision and environmental restrictions? Absence of a behavior for a period of time is not necessarily equivalent to a reduction in the risk of that behavior occurring; the increased observation and blocking of access to means are themselves largely designed to prevent the behavior. The decision to reduce monitoring should be based on the client's demonstration of new behaviors rather than simply a period of time in which overt SIB acts are absent.

As mentioned above, clinical interventions include teaching the client skills to address the function of the behavior and other critical variables identified in the behavioral analysis (also see McCann et al., 2007). The skills are practiced, learned, produced during role plays with coaching, and eventually expected to be produced without coaching or staff cues. Resident and staff are on the lookout for cues similar to the cue from the behavioral analysis, with the idea that these will be tests of whether the new skills are used. Cues need not be topographically identical (e.g., family not showing up for a visit again) to be sufficient; any event that leaves the resident feeling the same emotions, thinking the same thoughts, and experiencing similar urges at a similar level will suffice. Thus, it could be a heated argument by phone that leaves the resident feeling scared, angry, isolated, and having urges to end it all.

Units that include token economies can support the development of skills by linking progressively independent use of specific skills to earning of tokens. Such use of arbitrary reinforcements should always be supplemental to natural reinforcements for use of skills (e.g., verbally highlighting to the client that the use of a distress tolerance skill actually seemed to calm her down and then providing a token). Demonstration of skills in day-to-day life in the unit, including asking for staff assistance rather than impulsively self-harming, suggests that risk is somewhat diminished. Reliable and consistent skills displays provide further support for the hypothesis that risk is diminishing. Tracking ideation, urges, and actions (as well as the presence of intense emotions and other cues) on a daily diary card is also recommended as data are gathered to make the clinical decision to reduce monitoring and relax restrictions on the client's access to possible means to self-harm.

Conclusion

Increasing numbers of individuals with complex mental health and behavioral disorders in residential mental health and forensic settings suggest that rates of self-injury and suicidal behavior will continue to rise. Adding to the challenges for staff and other treatment providers in these settings is the difficulty of engaging and motivating residents and staff in often extreme environmental circumstances (Schmidt & Ivanoff, 2007). Developing and following clear guidelines in the prevention, assessment, and treatment of SIB using the methods described here is the best approach to reducing self-injury and suicidal behaviors.

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Date:Apr 1, 2014
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