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Non-suicidal Self-Injury: An overview for parents and practitioners

 

I have spent for many years researching and working clinically with individuals who engage in non-suicidal self-injury (NSSI). It is an area for which I have great interest and passion. There are so many loved ones and even clinicians who do not understand NSSI. The stigma and misunderstanding of these behaviors perpetuate the guilt and shame that people who engage in NSSI caring daily.

 

Below are excerpts from trainings I have given in the Dallas area to clinicians, teachers, and medical professionals. It gives a brief overview of NSSI; terminology, underlying reasons, treatments, and ongoing consideration clinically. I hope this information can help educate and support those who engage in NSSI and those who love and work with them daily. Please pass this along to friends, family and other practitioners. The more you understand the more you can support!

 

It should be noted that I believe it is important for a clinical to have some additional training or supervision in working with the NSSI client, as some of the behaviors can be challenging and physically harmful. Please obtain consultation from peers or supervisors as needed.

 

The basics:

Terminology:

There have many terms for non-suicidal self-injury over the years. However, NSSI is currently the most frequently used and accepted term. Others are antiquated and no longer used for various reasons. They either do not encompass the totality of the behaviors or indicate too narrow an understanding.

  • Non-suicidal self-injury (NSSI)-most recognized term

  • Self-harm

  • Parasuicide (no longer used)

  • Deliberate Self Harm (no longer used)

  • Self-Mutilation (too narrow)

  • “cutting” (too narrow, not clinical)

 

 

What is Non-suicidal self-injury?

  • Self-injury is a deliberate act against one’s self that inflicts harm.

 

 

It takes many forms.

  • Cutting, bruising, breaking bones, burning, picking, biting, opening wounds.

  • Other more covert ways: fighting, sports, ingesting items

 

 

What is Non-suicidal self-injury not?

  • Due to neurodevelopmental disorder

  • Socially acceptable (tattoo, piercing, religious/cultural rituals)

  • Suicide attempt

  • Does not occur during an intoxicated or psychotic state

  • Not part of stereotypical behaviors (i.e. head banging)

  • Not due to differential diagnoses (autism spectrum d/o, trichotillomania, movement d/o, etc)

*Taken from DSM-5

 

 

NSSI as a coping skill:

 

It is important to understand that NSSI is a coping skill! People are not engaging in the behavior to kill themselves but instead to gain some control or understanding over their feelings.

  • Why do we have coping mechanisms?

    • As a means to understand, regulate, and/or eliminate negative internal or external feelings, situations, and/or stressors.

  • Not suicide attempt:

    • “They are harming themselves in an attempt to continue living, not in an attempt to die.”

    • Yes, they want to escape the pain but not necessarily escape life.

How does hurting one’s self help the person cope?

  • Self-soothing/numbing: Releases of endorphins-calming

  • Emotional Regulation: A momentary lull in intense emotions

  • Distraction: Takes the attention away from emotional pain

  • Communication: Difficulty in verbal expression

  • Self-hate: Abuse history Deserving of punishment

  • Control Similar to eating disorders

  • Healing Watching physical pain/wounds heal

  • Reenacting abuse: To gain control or as part of a flashback

 

Clinical Implications:

 

When clinicians work with clients who engage in NSSI, there are many important factors to address. The following is a brief overview of some important areas.

  • Full and ongoing assessment of NSSI behaviors

  • Develop alternative coping skills

  • Ability to verbalize feelings

  • Communication skills

  • Rational thoughts/Cognitive restructuring

  • Alternatives to SI

  • No-harm contract? I do not use these for NSSI. It can perpetuate the feelings of guilt and shame.

  • Harm reduction? This is the idea of teaching the NSSI client how to harm themselves in a less harmful manner, so to speak.

 

Do’s and Don’ts

For clinicians, parents, teachers, friends and more…

 

Do:

Accept the person

Try to understand

Concern for injuries

Talk openly-assess often

Ask open-ended questions

Focus on strengths

Create a safe environment

Validate NSSI is a coping skill

Help them to take power back!

 

Don’t:

Be afraid to ask about NSSI!

Judge/shame/cause guilt

Make elimination the primary goal

Punish for injuries

Act shocked/disgusted

Be overprotective

Makes “deals” for them to stop

No “shoulding”

Say “how did that make you feel?”

 

Clinical Interventions:

  • Cognitive Behavioral Therapy: rational thinking

  • Art/Expressive therapies

  • Medication

    • Reduce depression, anxiety, PTSD sx

  • Group therapy

    • Specific clients, small group, skills based

  • Dialectical Behavioral Therapy

    • Addressing issues of crisis/intense emotions

  • Rational Emotive Therapy: (ABC model)

    • Activating Event, Belief, Consequence

 

 

References:

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

  • Bowman, S. and Randall, K. (2006). See My Pain. Creative Strategies and Activities for Helping Young People Who Self-Injure. Youth Light, Inc. Chapin, SC.

  • https://www.psychologytoday.com/blog/the-scarred-soul/200911/self-injury-does-it-matter-what-its-called

 

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February 10, 2017

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