Non-Suicidal Self-Injury
Youth Wellbeing Study Team
© Youth Wellbeing Study
Outline
 What is NSSI
 Why people self-injury
 Barriers to help-seeking
 Therapeutic strategies + Behaviour analysis techniques
 Websites
 Questions?
Why do people self-injure?
 Correlates of DSH (factors that exist alongside)
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Low self-esteem, self-defeating thoughts
Sexuality concerns (GLBT youth at risk)
Depression
Anxiety
Poor ability to understand and express emotion
Being bullied
Abuse history
Impulsivity
Drug and alcohol abuse
Low mindfulness
Low resilience
Why do people self-injure?
 International research shows:
 People self-injure for many different reasons
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Often multiple reasons
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Most common function is emotion regulation
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Self-injuring to escape from intolerable distress
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Useful framework is Experiential Avoidance Model
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Focus on emotional avoidance
But can include thoughts and sensations
Experiential Avoidance Model (EAM)
Chapman, Gratz & Brown (2006)
Why do people self-injure
 Metaphor of a volcano
 Self-injuring when bubbling emotions explode and become too
much to contain – way of releasing built up feelings or stress
when these feelings become overwhelming
 Other people use other behaviours to manage their volcanoes..
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Drinking, drugs, eating, reckless behaviours
Why do people self-injure:
Pastoral care staff interviews + focus groups
 4 Interviews and focus groups w/ pastoral care staff (N=7): Participants
attributed NSSI to a range of factors, particularly self-esteem, supports
available to them, and emotional difficulties:
“often the cutting..they have a self-image that is either unrealistic or unnecessarily
negative...I’m useless...I’m not good enough”
“Nice young girl who’ve been bought up to be polite, caring, empathetic, and looks
after others but tends to neglect her own needs...high standards of behaviour in the
household...anger is not allowed, so it’s suppressed, so they cut...they’ve got to let it
out somewhere, so this is how they do it”
“they do not have an emotional attachment that is functioning well enough for
them ...”
“...He would get really angry and then cut himself....sort of help bring him
down...”
Youth Wellbeing Study team, 2013
Barriers to help-seeking
 Often a secretive behaviour
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Tell nobody
Don’t seek help beforehand
Concealed body area (e.g. thigh); Clothing
Shame and guilt
 Personal factors
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Low self-esteem, poor ability to articulate emotions to others
 Factors in social environment
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Fear of others’ reactions
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Fear
Disgust
Anger
bullying
Taboo
Fear of being labeled/stereotyped e.g. ‘Emo’
 Friendships
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Have less friends to talk to + Friendship network deterioration
Clinical Implications
 NSSI is a common behaviour
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It’s worth asking about in routine assessments
Consider other issues
 Function of the NSSI
 Social Environment
 Responses from others to disclosure
 The majority of people self-injure to escape from intolerable distress
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But self-injury is complex
There are also other reasons for self-injury
 People who self-injure may also be suicidal => check for risk where
appropriate
Emotional Validation
Clients who self-injure may have reduced capacity to
understand and express their emotions. We can support the
development of these skills through validating emotions in
session:
Encourage emotional expression
Teach emotion observation and labeling
Read emotions
Directly validate emotions
Behaviour Analysis
 One of most important, and one of most difficult
sets of strategies in DBT
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BA strategic checklist
 Define the problem behaviour
 Conduct chain analysis
 Generate hypotheses
 Avoid … colluding with client in avoiding
behavioural analysis of targeted behaviours, …and
unduly bias information gathering to prove
therapists own theory of client’s behaviour (be the
naive inquirer).
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Analyse chain of events moment-moment
over time
Vulnerability
Problem behaviour
Prompting event
links
consequences
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Conducting a Chain Analysis
 Choose a specific instance of behaviour to analyse.
 Develop an exhaustive step-by-step description of
the chain of events leading up to and following the
behaviour.
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Attending to the links of the Chain
 Where to start? Ask the client when the problem began
(and what was occurring beforehand). When was it at it’s
peak? When it subsided/finished? What were the lasting
impacts?
 Clients can usually tell you when the episode began – at
least roughly.
 Overall goal: To link the behaviour to environmental
events; especially the ones they may not think are
linked/effect their behaviour.
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Filling in the links
 Think in terms of very small units of behaviour –
the links in the chain.
 Get info about what’s going on environmentally
and behaviourally (what client was doing, thinking,
feeling, imagining).
 You want to know how client got from one link to
the next – from here to there…
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Where to stop?
 The chain needs what leads up to the problem
behaviour as well as info about the consequences.
 Therapist wants to identify what is reinforcing
(maintaining) the problematic behaviour.
 Brief analysis of in session behaviours.
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Analyse chain of events moment-moment
over time
Vulnerability
Problem behaviour
Prompting event
links
consequences
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Identifying triggers for problem behaviour
 Triggers could include:
 Particular people + patterns of interaction with them
 Reminders of past experiences
 AOD use
 Particular situations, e.g. That cause stress
 Places where tend to self-injure
 Particular thoughts
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About themselves (negative self-talk), the past (sadness), the
future (anxiety)
Possible solutions
 Solve problem
 Change emotional reaction to problem
 E.g. by changing unhelpful believes or assumptions
 E.g. by changing levels of distress in the moment
 Tolerate the problem
 Stay miserable
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Distress Tolerance skills: crisis survival
 Reduction of acute destabilising emotions and
symptoms. Helps you feel better.
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Grounding
Relaxation – observing your breath, deep breathing,
measuring breath with footsteps, follow breath while listening
to music
Distract and soothe
One thing in the moment
Vacation – have a duvet day
Cheerlead yourself – I can stand it, this won’t last forever, I
will make it out of this, I’m doing the best I can, I can do it, I
am ok.
Distract !
To reduce contact with emotional stimuli
 Activity; physical exercise, clean your room, call or visit a
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friend
With thoughts; Count to ten, count colours in a painting, or
tree or window, do puzzles, watch TV, read
With emotions; act opposite to emotion, watch a comedy,
listen to emotional music, read emotional book/story
‘pushing away’ – build an imaginary wall between you and
the situation, or block the situation from your mind, censor
ruminating, put the pain on a shelf, box up the problem and
put it away for a while.
Using sensations – hold ice in hand, squeeze a rubber ball,
take a hot shower, listen to loud music, snap rubber band,
suck on a lemon, cold/frozen cloth on face, henna tattoo,
poor red food colouring (heated first)
Self Soothe!
 With the 5 senses
 Vision; buy one flower, look at beautiful pictures, look at
nature, watch the stars, paint your nails, be mindful of each
sight in front of you
 Hearing; listen to beautiful/soothing/invigorating music, sing
favourite songs, listen to sounds of nature, call weather phone
to hear a human voice, be mindful of the sounds letting them
in one ear and out the other...
 Smell; perfume, lotions, spray fragrance in the air, boil
cinnamon, bake cookies, cake or bread, smell the roses, smell
the outdoors, chai latte....
Self soothe cont...
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Taste; have a good meal, soothing drink, treat self to
dessert, sample flavours at ice cream shop, suck on
peppermint candy, chew favourite gum, eat mindfully
 Touch; experience whatever you touch, bubble bath, clean
sheets on the bed, pet your dog or cat, soak your feet, put
creamy lotion on body, cold compress on forehead, sink
into really comfy chair, put on silky top/scarf, brush your
hair for a long time, hug someone
Emotional (affect) regulation skills
 Mindfulness
 Delay action
 Learn what the emotion is from the client’s point of view
(non judgemental observation and description of emotion
in session – but clinician do not label – guide the labelling )
 Changing emotional responses: check on the facts, opposite
action (to emotion), problem solving, the half smile
Emotion regulation cont...
 Balance sleep, eating, mood altering drugs
 Build mastery in life
 Prepare ahead of time
 Self validation and cheerleading
Self care
 Self care box
 Important factors for self care
 (balanced) Exercise
 (balance) Food
 Sleep hygiene
 Limits/set boundaries
 Being able to say no
 Assertiveness
When…..
 I feel…
 I would like….
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Other ideas…
 Encourage re-engagement with life
 Joining a group (also good for distraction)
 Self-reflection and learning about identity
 Support for particular triggers e.g.
 Student learning support for exams
 Relationship services
 1:1 therapy to work through underlying negative self-talk
Websites
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The Low Down is a website that helps young people understand and deal with depression.
You can check them out at www.thelowdown.co.nz
Urge www.urge.co.nz
The Word - www.theword.org.nz
Embrace the future is a website that helps to educate young people in strategies and skills
which promote and sustain resiliency and positive mental health. You can check them out at
http://www.embracethefuture.org.au/
Fostering Resilience prepares young people for both good and challenging times. You can
check it out at http://www.fosteringresilience.com
The Resilience Research centre provides research looking at how young people and
families cope with different challenges. You can find out more information at
http://resilienceresearch.org/
SPARX website provides an e-therapy programme, offers a mood quiz to help young people
identify depression, and has information on where to get help. Website: www.sparx.org.nz
Ph. 0508 4 SPARX (staffed by professional counsellors 12 hours a day, daily).
 Questions? Comments?
 Please take copies of available resource sheets
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 Thanks for listening 