Prevention

Virtually nothing has been written on effective ways of preventing the adopting of self-injurious practices. Indeed, this is an area badly in need of research. However, we can begin to craft possible strategies by acknowledging dominant reasons for initiating and maintaining self-injurious practices and from lessons in related fields, such as disordered eating.

Enhance capacity to cope and regulate emotional perceptions and impulses. Inability to find alternate satisfying ways of coping with strong negative feelings is a highly consistent motivation for engaging in self-injury (Chapman, Gratz, & Brown, 2006). Indeed, one of the most common reasons for ceasing the behavior given in our recent student survey is the adoption of other coping mechanisms. It thus seems logical that effective prevention (and treatment) approaches will include a focus on enhancing individuals' capacity to cope with adversity. Indeed, this focus is one of the elements of Dialectical Behavior Therapy (DBT) - one of the more common and effective treatment approaches used with self-injurious behavior (Walsh, 2006). Broad agreement among mental health professionals that capacity to cope is declining in the general population of adolescent and young adults suggests that enhancing capacity to cope may also be a useful part of universal and targeted prevention approaches. Building on existing strengths and exploiting opportunities within institutional curriculum to help youth explore diverse methods of coping with negative feelings may help accomplish this objective.

Enhance social connectedness. Those who practice self-injurious behavior also report high levels of perceived loneliness, less dense social networks, less affectionate relationships with their parents, and a history of emotional and/or sexual abuse (Yates, 2004; Whitlock et. al., 2006). They are also more likely to suffer from diminished self-esteem, feelings of invisibility, and shame. Indeed, feeling invisible and inauthentic are common themes among self-injurious students we have interviewed for our studies. Approaches in which adolescents and adults are aided in recognizing and building on existing strengths, in reaching out to and connecting way with others in an authentic and meaningful way, and in participating in activities which allow them to feel meaningfully linked to something larger than themselves may help to shape a more positive view of the self. This may ultimately lessen reliance on potentially damaging coping mechanisms.

Avoid strategies aimed primarily at raising knowledge of forms and practices. Strategies aimed primarily at raising knowledge generally use single-shot or knowledge enhancement approaches to educate universal or targeted groups of youth about specific risk behaviors, practices, forms and consequences. In their review of eating disorder prevention strategies and research Levine and Smolak (2005) summarize research which suggests that single-shot awareness raising strategies (e.g., educational assemblies or workshops) are, at best, either not effective or only effective in raising short term knowledge and are, at worst, linked to increases in the behavior they intend to stop. Adverse effects were particularly evidenced in high school and college populations. Repeated and rigorous evaluation of the popular DARE program aimed at reducing drug use among youth has also been shown to be ineffective and, at worst, harmful (Lynam et al., 1999; Brown, D'Emidio-Caston, & Pollard, 1997). In many ways, these findings are consistent with common sense when regarded in the context of developmental processes - adult attention to specific risk behaviors, particularly if highly informative but of short duration or thoughtful follow-up, can be scintillating to adolescents interested in seeking adult attention or taking risks. Strategies which raise awareness about underlying factors (e.g. role of media or the cultural thinness ideal in promoting eating disorders) are not the same as those which simply educate about the prevalence, forms and practices associated with a specific issue and are likely to be more effective in positively raising awareness.

Equip staff and faculty to recognize and respond to signs of self-injurious behavior. Although it may be unwise to share detailed information about self-injurious behavior with large groups of youth, adults likely to encounter adolescents or young adults who engage is self-injurious behavior do need to know signs and symptoms. They also need to know what to do if they suspect or know someone is using self-injurious practices. Toward this end, raising awareness among adults as well as establishing protocols for referral is helpful for those who work directly with youth.

Focus on increasing staff and student capacity to recognize distress. As with many risk behaviors, our research shows that peers are most often the first to know or suspect that a friend is using self-injurious practices. As such, peers constitute the "front line" in detection and intervention. In light of the above recommendation to avoid awareness raising strategies about self-injurious behaviors with youth, we advocate concentrating effort on assisting young people recognize general symptoms of distress in their peers. Self-injurious behavior could be one of several categories of behaviors and perceptions assessed (mixing both positive and negative indicators avoids a soley deficit-based slant to findings) such as perceived wellbeing, eating disorders,life satisfaction, depression, relationships with adults, suicidality, etc. Additionally, while a few examples might be useful in explaining what is meant by self-injury, detailed description of forms could be avoided. In addition to educating about how to recognize distress, students could be encouraged to seek assistance and coached on specific strategies for getting help.

Promote and advertise positive norms related to help-seeking and communication about mental and emotional status and needs. It often requires more than a program or two to change embedded patterns. The tendency for peers to show loyalty to friends rather than to adults is strong (and, in many ways, fundamentally socially adaptive). Peers with knowledge of a friend's dangerous behavior are may be unlikely to share that knowledge with an adult without concentrated effort by adults to alter adolescent and adult norms about help-seeking and communication -- particularly communication between adolescents and adults. Strategies focused on altering community norms in social support and help seeking have been shown to be exceptionally effective in suicide prevention in a general population of adults in the US Air Force (Knox et al., 2003). Whether this approach will prove effective with self-injurious and suicide-related behaviors in adolescent and young adult populations is the subject of current research between this researchers with the CRPSIB and Dr. Knox of the University of Rochester.

Address sources of stress in external environment. The relationship between the sheer volume of stress or risk factors individuals confront and negative outcomes is well documented. Researchers have overwhelmingly shown that the more risk factors an individual confronts, the less like they are to thrive and the more likely they are to exhibit negative behaviors and attitudes (Sameroff, 1993; Rutter, 1989). The capacity to manage multiple stressors simultaneously is particularly difficult for children and adolescents who attempting to successfully meet core developmental needs as well. Although empirically impossible to verify, the argument that contemporary children and youth confront an increasingly complex and varied set of stress and risk factors when compared to previous generations is persuasive (Garbarino, 1995) and may be one reason for increases in rates of mental illness, including self-injurious behavior. If so, as Levine and Smolak (2005) argue for eating disorders, targeting environmental sources of stress may be a fundamentally more effective prevention strategy than targeting individual youth deemed to be at risk for self-injurious or other concerning behaviors.

Educate youth to understand the role media plays in influencing behavior. Media has consistently been shown to affect child and adolescent behavior in profound ways (Huesmann, Moise-Titus, Podolski & Eron, 2003; DuRant et al., 2003). Examination of the possible role media plays in spreading the idea of self-injurious behavior is one of the projects undertaken as part of this study program. Our preliminary findings support the assumption that images, songs, and news articles in which self-injurious behavior is featured has increased significantly over the past decade. As Brumberg (1992) has argued for eating disorders, highly visible public displays of self-injurious behavior may add potentially lethal behaviors to the repertoire of young people exploring identity options. Helping adolescents and young adults become critical consumers of media may lessen their vulnerability to adoption of glamorized but fundamentally poor coping strategies.