Academic journal article Best Practices in Mental Health

Treating Self-Injurious and Suicidal Behaviors in Residential Settings

Academic journal article Best Practices in Mental Health

Treating Self-Injurious and Suicidal Behaviors in Residential Settings

Article excerpt

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 setting 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 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, Eckenrode, & Silverman, 2006). Among ten- to twenty-four-year-olds in the United States, 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. …

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