Hidden side of a visible problem

Non-suicidal self-injury (NSSI) is well documented as a behaviour occurring in community settings and, sadly, there is now a generation of young people without significant psychiatric issues who self-injure. Many of these young people appear well adjusted with supportive social networks. However, the fact that they are turning to self-injury to help cope with the stresses of life suggests there are problems with managing psychological distress.

Non-suicidal self-injury (NSSI) refers to a range of distressing and disturbing behaviours that involve the intentional, self-inflicted destruction of body tissue without suicidal intent carried out for purposes that are not socially sanctioned (International Society for the Study of Self-injury, 2007). NSSI is therefore distinguished from behaviours that, while destructive to the individual, do not result in immediate damage to body tissue (e.g., restrictive eating), behaviours where suicidal intent is evident (e.g., overdosing on prescription medication), and behaviours that involve tissue damage that are socially acceptable (e.g., body piercing, tattooing, cosmetic surgery, and behaviours with spiritual, religious or tribal significance). Cutting is the most well-known NSSI behaviour, but NSSI behaviours may take the form of self-inflicted punching, hitting or slapping, scratching, biting, burning, gouging, carving words or symbols into flesh, piercing the skin with pins, interfering with wound healing, and breaking bones. Whatever the presentation, NSSI is difficult to treat.

In addition to this, on a public level, disclosure of self-injury practices by famous people such as Johnny Depp, Angelina Jolie and Christina Ricci may help to reinforce on a public level the notion of NSSI as an acceptable or even normalised behaviour (Whitlock, Purington, & Gershkovich, 2009). For young people experiencing feelings of isolation, online connections and social media can be appealing. These anonymous social media interactions help form important relationships with others to whom they can relate. The less positive aspect of social media is that it enhances the likelihood of social contagion, with many vulnerable young people connecting to similar others through social modelling in influential and high-profile songs, books, movies, and other communications. Alternatively, online communication can offer those who self-injure positive opportunities to find assistance to move them towards ceasing the behaviours.

Defining the terms

By definition, NSSI lacks suicidal intent and typically involves efforts to manage overwhelming emotional distress, such as anxiety, sadness, guilt, emptiness, or dissociation, so as to gain relief. NSSI is also more prevalent, and involves multiple methods (e.g., burning and cutting rather than more potentially lethal methods such as shooting or hanging) resulting in physical harm that is of low medical severity and rarely fatal compared to suicide attempts (Pompili et. al., 2015).

In contrast, suicidal behaviour generally involves an intention to end unendurable pain (physical or psychological) and is associated with the choice of a lethal method with high probability of ending one’s life, such as shooting, hanging, drowning, or jumping from a high place. However, it is important to emphasise that while NSSI and suicidal behaviours may have different intentions, both can occur within the same individual, making the relationship between self-injury and suicidality complex.

NSSI is typically associated with emotional and psychiatric distress, but the majority of people who self-injure do not intend to take their own life (Klonsky, 2007) and NSSI is most often performed in the absence of suicidal ideation (Klonsky, 2011). There is, however, much research evidence suggesting that NSSI is a strong predictor of future suicide attempts compared to those who have never self-injured (Klonsky, Victor & Saffer, 2014; Whitlock, 2009). Of those who do self-injure in community populations, 35 to 40 percent report some suicidality (Whitlock, Minton, Babington & Ernhout, 2015).

Importantly, engaging in self-injury is related to two important suicide risk factors: an increase in emotional distress and, inflicting pain and injury on oneself. Joiner’s (2005) Interpersonal Theory of Suicide suggests that habituation to fear and physical pain, such as that associated with suicidality, increases the desire and the capability to engage in lethal self-injurious behaviours. Accordingly, NSSI and suicidal behaviour may be considered on a continuum of self-injury behaviours, ranging from NSSI to completed suicide. Therefore, whereas NSSI is distinguished from suicidal behaviour, it should be assessed as an important risk factor for suicidal thoughts and behaviours (Ribeiro et. al., 2016).

The historical context

Much of the literature has conceptualised NSSI as occurring almost solely among those with a psychiatric diagnosis and as behaviours closely related to suicide undertaken to avoid the finality of the suicidal act (Menninger, 1938). In the 1960s, the focus shifted to the specific behaviour of wrist cutting. A ‘wrist-cutter’ was typically a young, intelligent, attractive, single woman, who experienced sexual dysfunction, had problems with interpersonal relationships and was likely to suffer with addiction. However, when researchers found that patients also injured many other parts of their bodies, research shifted away from wrist cutting. The need for a new research focus distinguishing NSSI behaviours from behaviours related to suicide began to be developed. Currently, there is a lack of consensus in the literature as to the definition of self-injury and researchers have used different assessment and classification systems to define self-injurious behaviours (Duggan, Heath, Toste & Ross, 2011). For example, the term ‘deliberate self-harm’, is regularly used to refer to self-injurious behaviours both with and without suicidal intent, and therefore includes both self-injury and suicidal behaviours. Since 2007, researchers have started to collectively embrace the term NSSI to better understand and address the issue, and disseminate the latest research developments (Lewis & Plener, 2015).

Who self-injures?

There is no particular kind of person who self-injures. NSSI crosses ethnicity, age, gender and social class. However, self-injury typically begins in early adolescence and peaks at mid-to-late adolescence. Studies have shown 20 percent of those engaging in NSSI reported onset between the ages of 11 and 13 (Jacobson & Gould, 2007; Klonsky & Muehlenkamp, 2007; Muehlenkamp & Gutierrez, 2004; Nock & Prinstein, 2004). Onset before age 12 has been associated with more frequent and severe NSSI and a higher likelihood of having a suicide plan (Ammerman, Jacobucci, Kleiman, Uyeji & McCloskey, 2018). Some studies have shown a second peak occurring at around 20 years of age (Gandhi et. al., 2018) and NSSI can begin as late as middle age or even older (Martin, Hasking, Swannell & McAllister, 2010).

A recent meta-analysis by Bresin and Schoenleber (2015) found strong evidence that girls and women are slightly more likely to engage in NSSI than boys and men, although in clinical samples a larger gender difference was evident. Gender differences may be masked by a greater tendency for females to disclose information about themselves in a research study and generally higher female participation rates in psychological research. Other possibilities include females being more likely to seek help with NSSI. Also, females are more likely to use NSSI methods that produce blood and are less easy to account for (e.g., cutting and scratching) compared to males who may use forms of self-injury such as banging of the head, punching the body and burning that can be attributed to accidental or thrillseeking activities.

Why do people self-injure?

Since the late 1990s many theories to try and explain the functions of NSSI have been explored (Klonsky et al., 2014; Suyemoto, 1998). Nock and Prinstein (2004) were the first researchers to introduce an empirically supported model to explain four main behavioural functions of adolescent NSSI that differ along two dichotomous dimensions. The consequences of NSSI behaviours can be either automatic (intrapersonal) or social (interpersonal) and reinforcement for the behaviour may be positive (followed by a favourable event or stimulus) or negative (followed by the elimination of an aversive stimulus).

Furthermore, they suggested that adolescents engage in NSSI for such reasons as, automatic negative reinforcement (to stop undesirable thoughts and feelings), automatic positive reinforcement (to generate some kind of feeling, even pain), social negative reinforcement (to escape interpersonal tasks or demands) and social positive reinforcement (to gain attention from others).

Not long after, Klonsky (2007) conducted a systematic review of the empirical evidence for seven functional theories of deliberate self-injury. The 18 studies included in the review answered several key questions about why people engage in NSSI and found:

• Emotion-regulation overwhelmingly emerges as the most commonly supported function of self-injury in both adolescent and adult samples. Negative feelings such as sadness and anxiety precede NSSI, and the act of NSSI reduces arousal and negative emotions resulting in feelings of calmness and relief (Klonskly, 2007). Explanations for self-injury include “to release emotional pressure that builds up inside of me,” “to manage stress” or “to stop bad feelings” (Klonsky & Muehlenkamp, 2007).
• More than half of those who self-injure endorsed self-punishment or self-directed anger as a motivation for NSSI (Klonsky, 2007). This is consistent with other research suggesting that a self-critical cognitive style involving intense negative feelings about the self, may be a specific risk factor for the development of NSSI (Hooley, Ho, Slater, & Lockshin, 2010; St. Germain & Hooley, 2012).
• People who self-injure endorse multiple functions of NSSI such as a desire to seek help from or influence others, or to create a physical sign of their emotional distress. Other NSSI functions identified include anti-dissociation (e.g., creating pain to end numbness), anti-suicide (e.g., to avoid or replace the impulse to commit suicide) and sensation-seeking (e.g., doing something to generate excitement).

Self-injury is everywhere

NSSI has become a not-so-silent epidemic around the world. Researchers across the globe agree that NSSI typically occurs at the age of 13 to 15 years and that generally 15 to 20 percent of young people in the community report engaging in NSSI at least once (Nixon, Cloutier, & Jansson, 2008). An international review of 52 self-injury studies showed a prevalence of approximately 18 percent of individuals who had cut or used other methods to intentionally hurt themselves in their lifetime (Muehlenkamp, Claes, Havertape & Plener, 2012). The Australian National Epidemiological Study of Self-Injury, the largest self-injury study in the world, with data collected from 12,006 Australians aged 10 to 100 years, was the first to look at self-injury in the community and across the entire life span. The study results were astounding, suggesting more than eight per cent of the Australian population had harmed themselves at some point in their lives.

When applied to the whole population, the study showed that over 200,000 Australians intentionally damage their own bodies every month, with the peak amongst adolescents and young adults where 9.4 percent of children (10 to 17 years), and 19.3 percent of young adults (18 to 24 years) reported having self-injured at least once in their lifetime (Martin, Swannell, Harrison, Hazell & Taylor, 2010).

Far from being a problem unique to troubled young females, self-injury can begin as late as middle age or even older, evidenced by the large numbers of people in their 40s and 50s who reported using NSSI as a coping mechanism. Amongst adults aged 25 to 100 years more than one in four reported self-injuring at least once.

Importance of care

There is a lot of misunderstanding about self-injury in emergency rooms and inpatient settings. NSSI can be, and is, frequently misunderstood as attempted suicide, because it often involves self-inflicted cutting of the wrists. Differentiating between NSSI and suicidal behaviours is critical to appropriately identify, conceptualise, and effectively treat these issues (Lofthouse, Muehlenkamp & Adler, 2009; Messer & Fremouw, 2007). Acts of self-injury designed to regulate some emotional distress can usually be treated on an outpatient basis, therefore, it is vital that clinicians understand how to distinguish NSSI from attempted suicide to make an accurate diagnosis and treatment plan.

NSSI is a challenge. In many ways it is distinct from suicidal behaviour, and should be managed as such. However, there are distinct characteristics and intentions between those who self-injure as a means of coping with overwhelming negative emotion and those who self-injure in order to attempt suicide. Perhaps one of the most paradoxical features of self-injury is that most individuals who self-injure report doing so as a means of relieving emotional pain or to alleviate a sense of emptiness and numbness. In contrast, suicidal intention usually involves choosing a highly lethal method with the intention to end one’s life. One thing we do know is that NSSI behaviours are associated with increased psychological risk (e.g., distress, isolation, and maladaptive coping mechanisms) and physical risk (e.g., scarring, infection and accidental death). Repeated acts of NSSI may also increase risk for suicidal thoughts, gestures and attempts. Barent Walsh (2012) recommends clinicians assess patients with respectful curiosity – a stance that is respectful, non-judgemental and takes the time to understand the functions of self-injury for an individual.

Treating NSSI

Giving up self-injury is very difficult because of the habitual nature of NSSI. Effective treatment involves cognitive behavioural skills training, and teaching people new ways to regulate their emotional experiences that allow them to give up self-injury. In clinical populations clients have often had aversive, abusive experiences. In these cases, they may associate their bodies with horrific, traumatic experiences. Exposure treatment may be used to free them from their histories of trauma and enable them to move beyond that history and to give up self-injury.

A number of different psychotherapeutic approaches have been shown to be helpful for individuals who self-injure. However, there are few evidence-based treatments which have been designed specifically for NSSI. This is concerning particularly when recognising the prevalence of NSSI amongst adolescents and young people. Consequently, clinicians are left with few clinical practice guidelines and empirically supported treatments for this challenging population.

CBT, particularly CBT interventions which integrate a problem-solving component, and dialectical behaviour therapy (DBT) designed to address other mental health concerns have shown the most empirical support for reducing self-injury behaviours (Muehlenkamp, 2006).

Cognitive behaviour therapy (CBT)

CBT focuses on changing the way individuals think, which impacts on the way they feel, which in turn directs behaviour. There is a skills development focus particularly on problem-solving including: developing adaptive coping strategies, techniques to plan ahead, managing exposure to difficult situations, cognitive techniques for identifying and challenging dysfunctional faulty thoughts, beliefs and attitudes and the over estimations of the probability of a negative outcome, and relaxation and calming techniques.

Dialectical behaviour therapy (DBT)

DBT, a form of CBT, has shown strong evidence for reducing self-injurious behaviours. DBT combines skills-training, exposure and response prevention, contingency management, problem-solving training, and cognitive modification strategies with mindfulness, validation, and acceptance strategies (Washburn et. al, 2012). DBT has been shown to be efficacious particularly as it addresses emotional dysregulation a commonly reported function of self-injury. DBT helps individuals cope with negative affect and develop problem-solving skills. It has been adapted for use with adolescents although there have been no randomised control studies to evaluate its effectiveness. However, DBT has become a foundation for working with individuals who are at risk of engaging in NSSI. The evidence shows that it is an effective treatment in reducing self-injury behaviours in adults particularly those with a BPD diagnosis.

Emotion regulation group therapy (ERGT)

ERGT combines parts of DBT, emotion focussed therapy (EFT) and acceptance and commitment therapy (ACT) and shows promise in treating adults who self-injure (Sahlin et. al., 2017). ERGT has been developed to target NSSI and the underlying mechanisms of difficulties with emotion regulation by helping individuals to develop more adaptive ways of responding to emotions. It addresses the dimensions of emotional awareness, understanding and acceptance, and the use of non-avoidant strategies to regulate emotions and acceptance of intense emotional states, particularly a willingness to experience negative emotions as part of pursuing meaningful activities and increasing emotional acceptance.

Treatment for self-injurious behaviours (T-SIB)

T-SIB is a nine-week behavioural intervention program designed to treat NSSI in young adults with and without a BPD diagnosis (Andover, Schatten, Morris & Miller, 2015). The treatment is designed to work as a standalone therapy or an adjunctive intervention and is a behavioural intervention focused on motivational enhancement strategies, functional assessment and addressing skills deficits in distress tolerance, cognitive distortions, problem-solving or interpersonal communication which underlie and contribute to NSSI behaviour. A pilot randomised controlled trial showed a decrease in NSSI frequency although further investigation of the utility of T-SIB is necessary.

Motivational interviewing

This is a common approach for addressing NSSI, with the focus on helping individuals to engage in healthy behavioural change by exploring the pros and cons of continuing NSSI and the alternative of developing more adaptive coping skills. Assessing an individual’s motivation to change is important and the Stages of Change model (Prochaska, DiClemente & Norcross, 1992) can help individuals to develop the self-knowledge required to move through all of the stages needed in the treatment of NSSI.

Resources for practitioners

Most individuals who self-injure typically do not seek treatment and are resistant to disclosing their concerns to clinicians (Nixon et al., 2008; Whitlock, Eckenrode, & Silverman, 2006). An effective therapeutic relationship is an important facilitator of change for helping individuals to engage in therapy and try alternative coping strategies (Nafisi & Stanley, 2007). During assessment clinicians should routinely ask about NSSI behaviours in a non-judgemental way, and they should respond with ‘respectful curiosity’ (Whitlock & Purington, 2013). This approach serves to understand both the individual and the purpose that the self-injury may serve. For example, asking “Why do you think self-injury works for you?” or “How does self-injury make you feel?”

The SOARS (Suicidal ideation; Onset, frequency, and methods; Aftercare; Reasons; Stage of change) Model is a risk assessment tool for NSSI which can be helpful as a brief screening and assessment of suicidal behaviours, duration, type of self-injury, motivations and readiness for change.

Time to act

NSSI has become more common, and its prevalence may be increasing in adolescent and young people. This makes it an important area of focus for psychologists. Awareness of the risk factors, an understanding of the risk for suicidal behaviours and completion, and increasing knowledge in assessment and treatment practices for people presenting with NSSI will place psychologists at the forefront of service delivery. There are few evidence-based treatments which have been designed specifically for NSSI and whilst some treatments show promise, further treatment outcome research is needed to clarify and assess the effectiveness of different therapy interventions for reducing NSSI behaviour.

Resources for the public

Mental Health First Aid Australia (2014) developed guidelines which may be helpful for members of the public in responding to NSSI prior to seeking appropriate professional help: bit.ly/2NnCkXR

A series of five informative e-books has been developed by the Centre for Suicide Prevention Studies at The University of Queensland under the series name “Seeking Solutions to Self-injury”. These guides inform a number of different populations (emergency staff, family doctors, school staff, young people; and parents and families) and provide an excellent basis for responding to individuals who engage in NSSI. Psychologists may also find these helpful: bit.ly/2xs6myS and bit.ly/2OvGiKI

The author can be contacted at [email protected]