Working with Non-Suicidal Self-Injury

In the mid-70s I took a job at a state hospital where I discovered that many inpatients were self-injuring. This was puzzling to me as it violated the assumption that humans are instinctively wired to seek pleasure and avoid pain.

When I researched the literature on what was then called “self-mutilation”, I found it to be sparse. When I began my doctoral studies in the early 1980s, I selected the topic for my dissertation and it has been with me ever since. My greatest teachers have been my clients who have recovered from NSSI.

The definition I prefer is “Non-suicidal Self-injury (NSSI) is intentional, non-life-threatening, self-effected bodily harm or disfigurement of a socially unacceptable nature, performed to reduce emotional distress and/or effect change in others” (Walsh, 2014). This definition requires some explanation. The very term Non-suicidal Self-injury conveys the crucial point that this form of behavior is not about suicide and does not pose risk to life. NSSI does involve intentional harm to oneself, usually tissue damage. In study after study the most common forms of self injury are self-inflicted cutting, wound picking, self-hitting and burning, but there are many other forms such as self-abrading, self-biting and scratching. Note that these behaviors generally pose little risk to life.

You will note that I used the term ‘self-effected’ in this definition as opposed to ‘self-inflicted.’ This is because some individuals – usually adolescents and young adults – may self-injure with each damaging the other. ‘Self-effected’ is a more inclusive term.

Also, I added the term ‘disfigurement’ to include behaviors such as chronic hair-pulling (trichotillomania) that may not cause much tissue damage but can be disfiguring as to bald spots on the head, eyebrows or eyelashes.

The words ‘socially unacceptable nature’ are included to differentiate NSSI from body modification around the world, including culturally endorsed tattoos, body piercings and ritualized scarifications. NSSI specialists generally differentiate such behavior from NSSI. Key aspects of this definition are the words ‘performed to reduce emotional distress.’

Decades of research have shown the primary function of NSSI is emotion regulation. In fact, psychologist Joe Franklin and colleagues have provided ‘pain offset relief’ as an explanation as to why NSSI works in the brain to reduce emotional distress. They note that the areas of the brain that manage physical pain substantially overlap with areas that manage emotional pain. These researchers contend that when someone self-injures and stops, the physical pain is relieved, and the brain is ‘tricked’ so emotional pain is relieved as well. This explanation is entirely congruent with what individuals say when asked the clinically useful question, “What does NSSI do for you?”. The large majority respond that it provides ‘relief’ or ‘release’ from emotional distress. As the definition indicates, a second reason for NSSI, and a less important one, is that it may ‘effect change in others,’ such as eliciting sympathy or reengagement. However, numerous studies have indicated that the intrapersonal pain relief function is far more important than the interpersonal role.

www.selfinjury.bctr.cornell.edu/perch/resources/how-does-self-injury-change-feelings.pdf

In many important ways. These include function, primary methods, frequency in individuals, and the relative importance/unimportance of "means safety." Let’s take these in order:

Function – The function of suicidal behavior is to permanently end intense pain. I generally prefer the word "misery" in relation to the function of suicide. People who are suicidal generally aren’t motivated to kill the body; rather, they want to stop unendurable psychological and/or physical pain – that is, misery. In contrast, the function of NSSI is emotion regulation, generally without suicidal intent. Oddly, it can be viewed as a "coping skill." Granted, NSSI is not a healthy coping skill in that it causes tissue damage, but it is effective in reducing emotional distress.

Method – The methods for suicide are remarkably different from those of NSSI. The primary methods resulting in death by suicide in the US (my place of residence) are gunshot (52.8 per cent), suffocation/ hanging (27 per cent), and self-poisoning/overdose (12 per cent). Note that cutting – the most frequent method used in NSSI – is not on this list. In fact, most recently, only two per cent of suicides in the US occurred by cutting, and these deaths were not by cutting the extremities as is most common with NSSI. As noted above, the most common forms of NSSI are low lethality behaviors including cutting (80.1 per cent), wound picking (46.2 per cent), self-hitting (42.5 per cent), and burning (24.8 per cent). Note that the methods alone speak to how suicidal behavior and NSSI are markedly different.

Frequency – The frequency of NSSI incidents in some individuals can be very high, numbering in the scores of incidents, even in the hundreds of episodes in their lifetime. Some individuals report self-injury multiple times per week for years, even decades. Fortunately, even persons with serious and persistent mental health challenges never report suicide attempts at such a rate.

Importance of means safety – Means safety, formerly known as "restriction of means," has been recognized as a crucially important way to prevent suicides for decades. See www.hsph.harvard.edu/means-matter. An important example is ensuring that suicidal individuals do not have access to firearms. Other means safety methods include barriers on bridges and in train stations to prevent suicides by jumping. In a similar vein, carefully dispensing small amounts of medications to suicidal persons is another common means safety technique. While means safety is imperative in preventing suicides, it is generally of secondary importance with NSSI. Realistically, it is not possible to create a sharp-free environment in homes, schools, hospitals and other environments. The same goes for other NSSI methods such as skin picking, self-hitting, self-biting and self-burning. These are next to impossible to prevent if a person is determined to self-injure. The evidence-based way to reduce NSSI is cognitive behavioral treatment such as Dialectical Behavior Therapy, as opposed to a means safety approach.

I find it inappropriate to refer to NSSI as “attention seeking”. This phrase is minimizing and disrespectful. NSSI involves emotional distress and tissue damage. It should be considered an important problem that is not to be minimized or treated dismissively. I urge professionals to respond to NSSI with a low-key dispassionate and non-judgmental demeanor.

My favorite question to ask someone who self-injures is “what does it do for you?” This question is respectful and conveys genuine, empathic curiosity. Moreover, it leads to extremely useful explanations as to function.

Recent research has shown that prolonged NSSI often morphs into suicide attempts. Risk increases if NSSI is ignored or not successfully treated. It is important to treat NSSI early on so that the “double trouble” of NSSI followed by suicidality does not occur.

Psychologist Joe Franklin has researched the topic of “pain offset relief.“ His laboratory work has shown that the brain region which manages physical pain overlaps considerably with the area that manages emotional pain. With “pain offset relief”, he contends that when someone hurts himself or herself and stops the NSSI, there is relief from the cessation of the physical pain.

In addition, his research has shown that when the physical pain stops, the brain is tricked and emotional pain is relieved as well. That is to say, NSSI really does work to reduce emotional distress in the brain. However, this does not mean that NSSI is a positive behavior. There are many disadvantages associated with NSSI such as scarring, body image problems, potential infection, social recoil from others and so on. 

I find Franklin’s scientific explanation entirely congruent with what individuals who self-injure tell me. When I ask, “what does it do for you?” they inevitably say, “it gives me relief or release.”

In my book, I argue that when NSSI surfaces in school settings, the correct action is to notify the parent(s) immediately – so that the parent is informed and can seek treatment for the adolescent and the family. Family dynamics often play an important role in adolescent NSSI.

The only exception to parental notification is when the student has reached the age of majority. In those cases, notifying parents requires the student’s consent. My book has an extended discussion of a school protocol to manage NSSI in students.

I generally do not recommend reading about NSSI for youth as it has too much potential for triggering social contagion. Texts pertaining to basic counseling techniques can be helpful for youth leaders.

As for parents, I recommend the revised editions of my own book, Treating Self-Injury: A Practical Guide and Michael Hollander’s Helping Teens Who Cut.

From a cognitive-behavioral point of view, the first step is to collaboratively identify the triggers for NSSI with the person who self-injures. Following this, strategize how to reduce and eliminate as many of the triggers as possible. For triggers that cannot be eliminated, the therapist and client identify alternative ways to manage the related distress.

The development of effective distress tolerance and emotion regulation skills is at the heart of treatment. Clients need to develop a roster of skills that are more effective than NSSI in reducing emotional distress. Research has shown that the treatment of choice is Dialectical Behavior Therapy or as an alternative, Cognitive Behavior Therapy.