(Bolt and Christenson are therapists for Aspen Achievement Academy headquartered in Loa Utah. Kirsten Bolt, M.Ed. LAMFT, kbolt@dtheaspenacademy.com is the Primary Therapist for Girls Groups and Jacob Christenson, Ph.D, LMFT, jchristenson@theaspenacademy.com is a Wilderness Therapist. This is a summary of their presentation at the National Association of Therapeutic Schools and Programs (NATSAP) annual conference in Tucson Arizona last January.)

This year's annual NATSAP (National Association of Therapeutic Schools and Programs) conference was held in Tucson, Arizona on January 20-22, 2011. This conference allows colleagues from across treatment programs to meet each other, reconnect from years of collaboration, share new ideas, as well as engage in presentations designed to keep us up-to-date in our work. This year's conference offered twenty-four presentations spread across five breakout sessions, as well as keynote addresses. These presentations gave NATSAP members several opportunities to participate in discussions about current research and trends, best practices regarding treatment, and ideas for improved coordination and transition among programs. There almost seemed to be too many great topics to choose from during each presentation block!

I (Kirsten Bolt) had the privilege to present this year with Dr. Jacob (Jake) Christenson. We are both therapists with Aspen Achievement Academy, working with adolescent girls and boys, respectively. Over the past year or so, we noticed an increase in our clients' self-injury histories and practices while enrolled in our wilderness therapy program. And this was no longer exclusive to our girls' group, but also occurring in our boys' groups. We noticed a pattern of contagion, in which other students describing their self-injury practices, or having visible scarring or marks on their bodies, seemed to trigger other students to use or try out this coping mechanism. We have seen a marked increase in the numbers of adolescents engaging in self-harm: Jake mentioned during our presentation that about half of the boys he works with have some experience with self-injury, as do a majority of our girls. With the heightened awareness of self-injury in movies, television shows, music, Internet sites, and schools, it makes sense that there would be a subsequent increase in therapeutic schools and programs.

I should explain self-injury before continuing much farther. In much the same way that drugs, over- or under-eating, sex, video games/internet, shopping, or raging sometimes help people cope with overwhelming emotions and difficult situations, purposely hurting oneself serves the same function, albeit unhealthy. Some people find incredible relief through cutting, burning, scratching their flesh, hair-pulling, or not allowing wounds to heal. There is a physiological process with self-injury in which endorphins are released, thereby helping a person feel better despite physical and emotional pain. Therein lies the addictive nature of self-injury: people engage in the behavior to feel better, which works short-term, but also keeps them stuck in the behavior and this self-reinforcing cycle long-term. Some people describe how seeing the scars and marks on their bodies triggers them to engage in self-injury. And for some people the associated guilt and shame can trigger more use of this coping strategy.

This behavior can be very alarming and disconcerting for parents, peers, line staff, and even therapists. I still cringe internally sometimes seeing severe self-injury marks and scars. I think there is a self-protective mechanism that causes that reaction, which can be magnified incredibly, when the scars are on your child. Because people who self-injure tend to feel a lot of shame about the behavior, it is crucial for anyone in a caregiver role to monitor their personal reactions. One of the worst things we can do is to express disgust or fear through our words or facial expressions toward people who already feel a great deal of shame about this behavior. Connected with this idea, we must also practice very good self-care in order to make that a reality.

Essentially, self-injury is practiced for a couple of reasons: 1) to calm and self-soothe when emotions or situations become overwhelming, or 2) to feel emotions or 'alive' when numbness is the norm. There also seems to be an emerging third reason: 3) communication. This is an important realization for therapeutic programs because it is easy to pathologize these clients and think they are crazy or freaks (hurting oneself intentionally is counterintuitive to most people). Instead of viewing what looks on the surface like manipulative behavior, try to see it as communication of a deeper need or issue. For example, you tell your daughter she cannot go out tonight with friends that you see as unsupportive, and moments later she has slashed her arms and is showing them to you in what seems like an attempt to make you feel bad for your decision. It would be very easy to either 'freak out' yourself and panic, or to be angry at her "manipulation." Instead, it can help to view her response as a means to communicate (albeit passively) about her underlying pain.

One of the most important practices we've found is the need to validate the underlying issues, feelings, and use of self-injury as a coping mechanism, while not reinforcing the behavior itself. In other words, we can address the behavior and accept the underlying needs, while also challenging the self-injury as harmful, both short- and long-term.

In our presentation, we reviewed a history of self-injury from today's influence of media, dating back to at least 496 BC. We discussed current trends and demographics, as well countered common myths with facts such as "self-injury does not equal suicide." We explored what functions this behavior serves, as well as motivations for stopping the behavior. It is important to assess the function the behavior plays, rather than the whys. We showed photographs and video to help de-sensitize people to the shock in seeing self-injurious wounds and acts. We provided an overview of assessment and treatment goals, such as interrupting rituals of self-injury, using healthier coping skills, improving communication skills, and treating the underlying issues. And we concluded by identifying key considerations for policies and procedures among therapeutic schools and programs, such as documentation, preventing contagion, and training staff quarterly.

It was a great experience to present at NATSAP's annual conference, but also just to attend informative presentations, reunite with some familiar and friendly faces, spend some time in a beautiful desert backdrop, and enjoy the 75-degree weather in Tucson.