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
