Coping by Injuring:
Understanding
Non-Suicidal SelfInjury (NSSI)
A training provided for the
School Nurses Association
Tiffany B. Brown, Ph.D., LMFT
University of Oregon
tiffanyb@uoregon.edu
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NSSI definitions, prevalence, features
NSSI and the microsystem (family, peers, contagion)
NSSI and suicidality
Treatment approaches
Prevention efforts
Support recommendations
Potential school protocol
What is NSSI?
We often misunderstand
self-harm.
Includes cutting, scratching, burning, picking scabs or
interfering with wound healing, punching self or
objects, infecting oneself, and bruising or breaking
bones.
 Sudden and recurrent intrusive
impulses to hurt oneself.
 A sense of being “trapped.”
 An increasing sense of agitation,
anxiety, and anger.
 A constricted ability to “problem
solve” or to think of reasonable
alternatives for action.
 A sense of relief after the act of
self-harm.
 A depressive or agitated-depressive
mood, although suicidal ideation is
not typically present.
(Pattison & Kahan, 1983)
Prevalence
Prevalence
• Studies among community samples indicate that
approximately 13%–45% of adolescents report
having engaged in self-harm at some point in their
lifetime (Nock, 2010).
• On average, across studies, there is a prevalence rate of
15-20% for adolescents in community samples (Heath
et al., 2009).
• To put into perspective…NSSI exceeds the rates of other
important clinical problems.
• Anorexia/Bulimia <2%
• OCD <3%
Prevalence
• Massachusetts Youth Risk Behavior Survey (2008)---data
indicated 17% of HS students and 16% of MS students
reported having self-injured during the past year.
• In a recent adolescent community study the prevalence
rate of NSSI using the proposed criteria for DSM-5 was
6.7% (Zettergvist et al., 2013).
• Research indicates that these rates are even higher in
clinical populations with 40-60% of adolescents.
Prevalence
• Average age of onset is 12-14 years old (Nock,
2010).
• In clinical samples females report more NSSI than
males, whereas in community samples there is
usually no gender difference (Heath et al., 2009).
• Research is finding higher rates among Caucasian
and LGBTQ identities (Nixon & Heath, 2008).
• To date, there lacks a comprehensive epidemiology
study about NSSI.
Prevalence
• A recent study from Cornell and Princeton
Universities, using a sample of almost 3000 students,
found that 17% indicated having self-injured
(Whitlock et al., 2006).
• In a follow-up study involving 8 colleges and more
than 11,000 students, Whitlock (2008) found that
15.3% reported some NSSI lifetime; 29.4% reported
more than 10 episodes.
Self-Harm Features
The Role of NSSI
• The most expressed notion about the role of NSSI is
that it helps the individual escape, manage, or
regulate emotions.
• Self-punishment
• Anti-dissociation
• Resisting suicidal urges (stay alive; prevent suicide)
Nearly 50% of self-harming individuals report physical
and/or sexual abuse during childhood.
As high as 90% report they were discouraged from
expressing emotions, particularly anger and sadness.
Typically, self-harming individuals have a low selfesteem and a lack of healthy coping mechanisms.
Self-harm plays a role in reducing emotional pain and
serves as a coping mechanism.
The brain begins to connect
the temporary relief from bad
feelings to the act of selfharm.
It craves this relief the next
time the tension builds.
The behavior reduces
physiological and
psychological tension rapidly.
The negative feedback received in regard to
their injuries would often trigger more selfharm due to the increased guilt and shame
(Yip, Ngan, & Lam, 2003).
The most common motives
chosen from a list of
possibilities were to get relief
from distress and to escape
their situation (Rodham et
al., 2004).
“
We just didn’t see any
other emotions that we
were supposed to display.
Knew they were out
there, I just didn’t know
how to express them.
”
“
I would say that [the abuse]
affected me, in the sense of
not being able to handle
things, not being able to cope.
I didn‘t learn that. I didn’t learn
to cry safely. I didn’t learn how
to share my emotions safely. I
didn’t learn how to ask for help,
in fact, I learned how to not
ask for help.
”
Trina
Microsystem
Family Dynamics
• People who self-harm describe similar themes within parent-child
interactions that impact the development of self-harm as a coping
mechanism
• Dysfunctional and invalidating family environment (e.g., child
abuse and neglect, ignoring or rejecting a child’s emotional
expression, reinforcement of extreme emotions of negative affect)
• Attachment relationships (e.g. events or injuries to parental
bonding and attachment can disrupt the development of
emotional regulation capabilities, poor relationship quality )
Family Dynamics
• NSSI can arise as a learned response to insecure attachments and
attachment injuries.
– The student develops a strategy that allows him or her to self-regulate
and maintain a functional relationship with the caregiver despite his or
her limitations.
– This maladaptive attachment experience is internalized by the child
and creates a narrative that informs and impacts future relationships,
where there is often difficulty forming satisfying and secure
attachments with others  therefore, adolescents whose parents may
be unavailable need to focus on creating a secure attachment with
another adult (i.e., foster parent, grandparent).
• Parents would benefit from support as they struggle with their
own intense emotions around NSSI.
• Parents also need direction to SLOW DOWN and NOT OVER
REACT.
Peer Dynamics
• Contagion effect
• Peer influence processes (e.g., role of peer conformity,
peer socialization effects, peer selection effects,
shared stressors)
• Possible peer treatment approaches:
Psychoeducational group therapy, The Signs of SelfInjury Program (SOSI program)
Differentiating
Suicidality
Self-harm behavior is NOT suicidal behavior
Those who self-harm want to live but they feel the only way
to remain in control, sane, intact, etc, is to self-harm.
This does not mean that suicidal ideation does not exist, but
shouldn‘t be assumed just because of the self-harm
behavior.
1%
Less than
of those who selfharm endorse wanting to die as a
precipitating reason.
(Rodham, Hawton, & Evans, 2004)
NSSI and Suicide
• NSSI is a risk factor for subsequent suicidal behaviors.
• NSSI can be mistaken for suicide attempts - and vice
versa.
• Some individuals report both NSSI and suicide
attempts.
NSSI and Suicide
• NSSI is associated with higher risk for a suicide attempt
when the following are present:
– Higher levels of suicidal ideation
– Severity of depression
– Diagnosis of Borderline Personality Disorder
– Impulsivity
– Greater levels of negative affect
– Apathy & hopelessness
– Self-derogation/lack of self-acceptance
Brausch & Gutierrez (2009); Muehlenkamp(2010)
NSSI and Suicide
• Risk Factors
– Severity and duration of NSSI (increased suffering)
– NSSI becoming less effective in reducing emotional distress
– Worsening mental health symptoms
• Protective Factors
– Hope
– Family connectedness, support
– Peer social support
Brausch & Gutierrez (2009); Muehlenkamp(2010)
“
I don’t really correlate
the two…there’s
several ways to
[self-harm], you
know. Some people
will pull out their
hair. I’ve never
heard of someone
killing themselves
by pulling out their
hair.
”
“
They’re different
because suicide is a
permanent solution
to a temporary
problem and selfharm is my way to
deal with those
temporary problems.
”
“
I was never
suicidal, ever, and
that is not what
needs to be treated.
What needs to be
treated is our
inability to deal
with things.
”
Treatment
Approaches
Dominant Approaches
• Cognitive behavioral therapies (standard cognitivebehavioral therapy, manual-assisted cognitivebehavioral therapy, problem-solving therapy, and
dialectical behavior therapy)
• Group therapy (developmental group psychotherapy,
Acceptance-based emotion regulation group therapy)
No evidence-based pharmacological treatments for selfharm
Limitations of Current Approaches
• There are no evidence-based treatments for NSSI.
• The current research on NSSI presents inconclusive results on
the most effective treatment approach.
• Themes underlying the treatment modalities that have
demonstrated results include addressing maladaptive
emotion regulation, intervention programs that serve as an
adjunct to treatment as usual (e.g., group therapy),
treatment approaches designed to reduce NSSI for
individuals diagnosed with borderline personality disorder,
and the integration of group therapy.
• Lack of studies that address NSSI directly.
• Little research focus on treatment of NSSI specifically for
children and adolescents.
• There are no empirical research studies investigating relational
or family treatment approaches.
Treatment Recommendations
• Utilize treatment approaches that emphasize emotional
awareness, emotional acceptance, and emotional
regulation, as well as use of healthy coping skills.
– Good options are DBT (Linehan, 1993), Mindfulness BasedCBT (Crane, 2008) and ACT (Luoma, Hayes, & Walser, 2007).
• Actively involve family members in treatment and
consider approaches that emphasize attachment.
• Utilize mindfulness and stress-reduction techniques.
• Teach social skills and interpersonal effectiveness.
– Have the student keep a log or journal about their
experiences with self-injury and what thoughts, emotions,
and situations are happening when they self-injure, as this
information can help them realize when they need to
practice newly obtained coping skills.
Prevention
Prevention Efforts
• Despite the apparent need for prevention programs,
there are no known evidenced based programs
currently in use.
• Fortune et al. (2008) found that adolescents believed
the best way to prevent self-harm are:
– Acess to non-judgmental adults at school
– Provide education to teachers, peers, and parents about
how to appropriately respond
– Reduce concerns about confidentiality and stigma with
seeking help
Signs of Self-Injury (SOSI)
• 2 modules (faculty/staff and students), including a
DVD for students
• Encourages students to use ACT (Acknowledging the
signs, Care for the person and a desire to offer help,
and Tell a trusted adult.
• SOSI Goals:
– Increase knowledge of NSSI
– Improve attitudes and perceived capability to respond and
refer students or peers
– Increase help seeking behaviors
– Decrease NSSI acts
SOSI Outcomes
• Improved attitudes in students towards acceptance
& helping those with NSSI
• No iatrogenic effects reported
• Help seeking behaviors increased (but not
significantly)
• Feasibility data = Very positive from school staff
• NSSI acts declined (but not significantly)
• Program has initial promise; more research needed
Muehlenkamp, J.J., Walsh, B.W., & McDade, M. (2009). Preventing non-suicidal self-injury in
adolescents.
Support
Recommendations
Your Response
• Be mindful of your role and position (e.g., power).
• Make eye contact and speak in calm tones.
• Start with your care for the student and desire to offer support.
Normalize the behavior.
• Focus on the desire to cope/express versus the self-injury.
• Be direct and specific about your concerns and why you have
them.
• Balance confidence and curiosity. Let the student teach you about
their experience.
• Remain neutral in your responses and don’t characterize selfinjury as “bad.”
– Students who self-injure may be particularly vulnerable to
perceived criticism or heightened emotional response.
• When a student is discussing and disclosing self-injury, prepare
yourself ahead of time.
Understand Triggers
– Trauma related events
• Flashbacks/memories
• Seeing the perpetrator
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–
–
–
–
Touch (even good touch)
Family contact
Self-disclosure
Minimizing
Problem talk
Secrets
Support/Help
– Reaching out (no follow
through)
– Anxiety/Nerves
– Unregulated emotions
– Guilt
– Shame
– Sadness
– Anger
– Scars
– Wounds/Injuries
Support
Plans
Understand triggers.
Discuss how active the self-harm is
and plans to stop.
Map out the students’ support
system.
Understanding who is good
support and who is not.
Assess suicide, but in a caring and
non-reactive way.
What helps?
Journaling (usually most helpful)
Expanding support system
Plans, contracts (if done correctly)
Harm reduction
Breathing/grounding techniques
Learning to set boundaries
Working through trauma(s)
Being overt and modeling emotional
expression.
Physical exercise (assess ED first)
Support groups
Being with someone who genuinely cares
(YOU).
Response DO’s
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•
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•
•
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Acknowledge the behavior as something you are familiar with
Forge an alliance with the student
Listen and acknowledge feelings
Take their concerns seriously
Respond without being directive or judgmental
Create a safe and caring place for the student to talk, cry, or rant
without criticism of feelings
• Process with a colleague if you are worried about your response
• Provide HOPE!
Response DO’s
• Discuss with parents/guardians …
– How to establish a secure attachment with their child
– The effects of repression and/or mismanagement of emotions
– Stress around family secrets
– Healthy and appropriate boundaries
• Discussion with adolescents about...
– Function or role of self-harm
– Alternative coping strategies
– Healthy and appropriate boundaries
– Peer relationships
– Social support
Response DON’Ts
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•
•
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React with horror or discomfort with the disclosure
Ask to see the scars/wounds
Immediately call a parent/guardian without other steps
Ask abrupt and rapid questions
Threaten or get angry
Engage in power struggles and demand they stop
Mandate therapy/hospitalization
Accuse them of attention seeking
Get frustrated if behavior continues
Ignore other warning signs (i.e., family issues, suicidality)
“
Don’t make the person feel worse about it. I
think there is already enough shame that goes
along with it.
”
“
Yes, it’s
that easy,
if it was
that easy I
wouldn’t
be here.
Obviously
it is not
that easy,
otherwise
I would
not come
to YOU.
”
School Protocol
Example
School
Awareness
Point person
meets with the
student
Nurse treats (if
needed)
Low Risk
Moderate/High
Risk
Some Notes About Contacting Parents/Guardians
1. Do not call without discussion with student first.
Calls should never be automatic.
2. Understand home situation and make plans to call when it will
not put the student at risk.
A call to DHS may be more appropriate.
3. If a call to a parent/guardian makes the most sense, spend time
with the student to discuss how it could go. Make a plan. Use
your relationship to help them feel supported.
3. Continuously involve parents/guardians with follow ups.
4. Document parent/guardian contact and their response.
Allow the student to
teach YOU about their
experience. They are
the expert on their
NSSI.
Believe that you CAN
be helpful.