Assessing and Treating Non-Suicidal Self-Injury

Editor's Note: This text-based course is a transcript of the webinar, Assessing and Treating Non-Suicidal Self-Injury, presented by Patrice Berry, PsyD, LCP.

Learning Outcomes

• After this course, participants will be able to explain non-suicidal self-injury, discuss different types of self-injury, and dispel common myths about self-injury.
• After this course, participants will be able to identify ways to assess for non-suicidal self-injury, safety plan, and common reasons why people engage in this behavior.
• After this course, participants will be able to identify clinical approaches to consider when treating non-suicidal injury.

Introduction

• Why is this important for psychologists?
  • Learning how to address non-suicidal self-injury applies to psychologists in all settings (School/Education, Justice System, Medical/Hospital Settings, Community Programs, Outpatient Clinics, Residential/Group Homes, etc.)

I am excited to be here, as this is a topic for which I am passionate. This topic is essential for psychologists to learn how to address non-suicidal self-injury across all settings, from schools, justice systems, both juvenile and adults, medical and hospital settings, community-based programs, outpatient clinics, and also residential and group homes. I have worked in many settings throughout my career, and I have seen individuals present with self-injury in each one. Knowing what to look for and how to help individuals is essential. We need to see things from their perspective and connect with them.

Limitations

• Some of the treatments listed in this presentation require additional training, and this training is not a comprehensive review of these treatment protocols.
• Mental Health professionals are responsible for reviewing scope of practice, including activities that are beyond the boundaries of practice in accordance with and in compliance with your professional standards.

Here are a few limitations of this presentation. Some of the discussed treatments require additional training. Today's training will not comprehensively review all of those treatment protocols. For example, I will mention dialectical behavior therapy (DBT), but training is needed to be proficient in that treatment.

Mental health professionals are responsible for reviewing the scope of practice, only engaging in behaviors within their scope of practice, recognizing the boundaries, and complying with their area's ethical and professional standards.

Terms Defined

• Suicidal Ideation-Thoughts of wanting to die
• Suicide Attempt-Acting on thoughts of wanting to die
• Thoughts of Self-harm-Thoughts about harming self
• Non-Suicidal Self-Injury (NSSI)-Acting on thoughts of harming self

(Donath, C., Bergmann, M. C., Kliem, S., Hillemacher, T., & Baier, D., 2019)

I want to define some terms. Suicidal ideation is thoughts of wanting to die, and a suicide attempt is acting on those thoughts. Thoughts of self-harm include thoughts of engaging in any self-harm, which could be related to a possible suicide attempt, or might not. Non-suicidal self-injury is acting on those thoughts of self-harm.

We are differentiating between a suicide attempt and non-suicidal self-injury because you will approach these in very different ways. I will have a different approach with an individual who presents with non-suicidal self-injury versus somebody who is presenting to a hospital after a suicide attempt. We will get more into this a little bit later. I will also be using the acronym NSSI for non-suicidal self-injury.

Examples of Types of Self-injury

• Cutting
• Scratching
• Head banging
• Pinching
• Hair pulling (Trichotillomania)
• Biting nails to the point of bleeding
• Punching self or objects
• Carving words or images into skin
• Burning
• Rubbing sharp objects
• Teeth Pulling
• Eating sharp or dangerous things (not pica)
• Putting needles or objects under the skin
• Breaking bones
• Intentionally reopening healed wounds

https://www.healthyplace.com/abuse/self-injury/10-ways-people-self-harm-self-injure

Here are some examples of different types of self-injury that come from healthyplace.com. There is a long list of ways an individual might engage in self-harm. The most common that we hear about is engaging in cutting. Self-harm can also include scratching, head banging, pinching, hair pulling, biting nails to the point of bleeding, punching to feel pain, carving words or images, burning oneself, rubbing self until it hurts, rubbing sharp objects, teeth pulling, eating sharp or dangerous things (not associated with pica), putting needles or objects under the skin, breaking bones, or intentionally reopening healed wounds. When a client presents with injuries, I assess if it is an accident or from self-harm. Being able to differentiate between those is very important for treatment.

Special Note

• NSSI is in the DSM 5 listed as a "condition requiring further study."
• Criteria if the person does not meet criteria for depression, anxiety, eating disorder, substance abuse, or trauma-related disorder
• NSSI common symptom within Borderline Personality Disorder, along with suicidal self-injury, suicidal gestures, and/or suicide attempts
• Cultural Formation Interview

(Hooley, J. M., Fox, K. R., & Boccagno, C., 2020; Lewis-Fernández, R., Aggarwal, N. K., Hinton, L., Hinton, D. E., & Kirmayer, L. J. (Eds.), 2016)

In the DSM 5, they have listed non-suicidal self-injury (NSSI) as a condition for further study, and the references are listed there. You will only use that particular diagnosis if the person does not meet the criteria for depression, anxiety, or eating disorders or if symptoms are not better understood within another diagnosis. Non-suicidal self-injury, along with making suicidal statements, gestures, or attempts, are also very common with a borderline personality disorder. Sometimes, people do this as a way to regulate their emotions. Practitioners with this education and understanding use a non-judgmental approach to connect with the person to help them find other ways to express those intense feelings.

The Cultural Formation Interview within the DSM 5 might be helpful if you are working with somebody from a different culture. You need to know how this behavior is seen within their culture. We do not want to pathologize something if it is part of certain spiritual or religious rituals. The Cultural Formation Interview has some great questions within the DSM 5 about how you can understand things from a client's perspective.

Common Myths About NSSI

• Self-injury is rare
• Self-injury always requires hospitalization
• Self-injury is only for attention
• If they really wanted to die, they would cut deeper
• Self-injury is only cutting
• Tattoos and piercings are a form of self-injury
• Nothing helps/there is no treatment

(Klonsky, E. D., Victor, S. E., & Saffer, B. Y., 2014)

https://health.usnews.com/health-news/health-wellness/articles/2014/12/26/myths-and-facts-about-self-injury

(Solís-Bravo, M. A., Flores-Rodríguez, Y., Tapia-Guillen, L. G., Gatica-Hernández, A., Guzmán-Reséndiz, M., Salinas-Torres, L. A., Vargas-Rizo, T. L., & Albores-Gallo, L. 2019)

There are common myths about non-suicidal self-injury.

Myth #1

Some people feel that it is rare when it is pervasive, especially among adolescents. Different studies say anywhere between 30 to 40% of adolescents have attempted some form of self-harm. They must have the proper treatment and professionals, primarily because by the time the behavior comes to light, the person has often engaged in it for a while. It could be anywhere from a few months to a year or more.

Myth #2

The second myth is that self-injury always requires hospitalization or that you would automatically seek hospitalization with any form of self-injury. Research has shown that maintaining them on an outpatient basis and not sending them to the hospital is a better option. Sometimes hospitalization can worsen their symptoms. You will do your standard safety planning if somebody engages in this behavior, and we will discuss it in depth, including the specific questions to ask. If the person has an injury that requires medical attention, we will refer them to the appropriate doctor or ER for treatment. Still, they do not automatically need to go to the hospital.

Myth #3

Something that I often hear from parents is the myth that self-injury is only for attention or so that other people see it. Self-injury is often a hidden and private act and is always a negative coping skill. It is always a way to cope with pain, what the person is going through, or meeting an unmet need. If a teenager is looking for additional attention, we want to help them find healthy and appropriate ways to get attention or uncover what is under that pain. We see the best success when we address the pain underlying the behavior. Often, I see people overreact to the behavior and not try to understand what the person is going through. We want to help teach them skills to get their needs met.

Myth #4

Number four is that they would have cut deeper if they wanted to die. I have heard people say things like this. This statement is very dismissive and puts the behavior aside instead of taking the self-injury seriously. Even though I say do not immediately hospitalize, we still need to pay attention to the behavior and get some treatment. We should pay attention because there are often other things going on within the individual, and we want to be able to meet those needs.

Myth #5

The next one is that self-injury is only cutting. We discussed this myth previously when we went over that self-injury can include many different things. I have even had some people intentionally antagonize a pet so that the pet would scratch them. The goal was they wanted to cause some form of pain to be able to cope, and that was a form of self-injury for them.

Myth #6

Myth six is that tattoos and piercings are a form of self-injury. Tattoos and piercings can be a form of expression. You need to determine if the client felt like harming themselves when participating in those activities.

Myth #7

It is not an all-or-nothing thing but rather a gray thing, which is why we will talk about dialectical behavior therapy a little bit later in this training. Some people will feel like nothing helps or there is no treatment. I think why this myth exists because it is not a linear behavior. It is not like somebody starts and stops. For some people, it can be a cycle. The person can be in treatment for a while, and then they might engage in the behavior again. We then need to come back and treat it again. There are evidence-based approaches that are extremely helpful, and this is something that can be treated. We will talk about some treatments a little bit later.

Signs of Self-Harm

• Unexplained marks or injuries/bandages or injury does not match explanation
• Long sleeves when it is warm outside
• Marks in private areas (breasts/chest, upper thighs, etc.)
• Covering wrists or forearms
• Injury does not match explanation
• Posting pictures of self-harm on social media

(Pritchard, T. R., Lewis, S. P., & Marcincinova, I., 2021).

Some signs that somebody may be engaging in self-harm include unexplained marks or injuries, bandages, or if the damage does not match the explanation. If you have a good rapport with them, they may tell you. Clients may wear long sleeves when warm outside or long pants and hoodies instead of their typical shorts and t-shirts. You can check with them to see if they have engaged in self-harm. Some people have chronic thoughts of self-harm, while others have thoughts and behavior. It is essential to work on safety planning and help them feel safe enough in sessions so they are honest about the thoughts and feelings that they are having.

They may have marks on private areas, which is not something that I typically ask. However, a client may say that they intentionally did self-harm in a place where a parent or somebody is not going to see it or is covered by clothes. This is where you can see some of the guilt and shame that can come up about engaging in these behaviors. You want to stay grounded and connect with them to have a therapeutic, non-judgmental relationship. My face is very expressive, so I am mindful of my expressions when asking these questions or when clients self-report this behavior. I try to understand what is happening instead of focusing on the behavior. I want to know what happened before the self-harm. How was the person's day, sleep, or what led to this? Often, there is a buildup that has been happening over time.

Somebody may cover their wrists or forearms if that is where the injury has occurred. The injury may also not match the explanation. For example, they may say it was their cat, but there are precise marks. You need to use your clinical judgment to determine how to create a safe relationship.

Recently, I have seen individuals posting pictures of self-harm on social media. I see this mostly with teenagers. It can start as early as childhood, and research has shown it as early as eight or earlier. Typically, eight to 18 are peak times for kids and teens engaging in this behavior and then posting it online. A parent or relative will see this and inform the therapist or the school psychologist.

Assessing for NSSI

• Informal
  • Nonverbal
  • Verbal
• Formal
  • Critical item endorsement of actions ("When things get tough, I normally do something to harm myself)
  • Critical item endorsement of thoughts ("Thoughts of hurting myself)
  • DSM 5 Clinician-Rated Severity of Non-suicidal Self-Injury (Level 0 - Level 4)

Gratz, K. L., Dixon-Gordon, K. L., Chapman, A. L., & Tull, M. T. (2015). Diagnosis and characterization of DSM-5 non-suicidal self-injury disorder using the clinician-administered non-suicidal self-injury disorder index. Assessment, 22(5), 527–539.

You must assess what has been happening and how we best help this individual. My goal is to help first instead of stopping this behavior. If we only focus on stopping the behavior, the person might start to engage in another negative coping skill. Non-suicidal self-injury is closely tied with that lack of ability to manage emotions appropriately and intense feelings of overwhelming within their life.

Here are some tips for assessing for non-suicidal self-injury. There is an informal assessment where you ask during your intake. I am going to go over example questions in a moment. I often send them a document, a nonverbal tool, that asks about self-injury. A parent also may report that their child is engaging in this behavior. Other questions asked are about thoughts of harm to self and others, hallucinations, and other pertinent things. I always want to check in on this, especially for somebody that is presenting for therapy with significant depression, anxiety, bullying at school, and different things like that.

Verbally, I will ask questions related to this topic. You can work with somebody for a while, and they do not disclose this. However, it can come up later on. As I said earlier, there is often guilt and shame, which leads to secrecy. They must have a calming, safe person. I want to make a special note that when you work with kids and teens, you must ensure that they know what you need to disclose to parents. Ethically, it is anything related to safety. You must all partner together, so the client feels safe enough to let you know if they have engaged in the behavior. Let's say the client engaged in the conduct a year ago, and the parents are aware. However, they might not know the specifics of your confidentiality agreement. This agreement should include what you share with parents and what you are not communicating. And if you are working with an adult engaging in self-harm, have another person in that safety planning process.

There are also formal assessments. The DSM 5 has a clinician-rated severity of non-suicidal self-injury, with zero being the lowest level and four being the highest. This is a clinician-rated scale that you can use to track behavior over time, which might be helpful. Personality assessments, like the MMPI, the Personality Assessment Inventory, the PAI, and an assessment within the BASC, have questions about self-harm. An example may be, "I normally do something to harm myself." If somebody acknowledges that, I want to ask additional questions like, "What do you do?" to get an idea of the thoughts behind that. Was it to relieve pain, or was this an attempt? They may take a different approach if it is a past attempt versus non-suicidal self-injury. 

Example Questions to Ask During Assessment and Safety Planning

• Are you having thoughts about harming yourself?
• Are you having thoughts about dying?
• How have you harmed yourself in the past? (Give examples to lower the shame, cutting, punching walls, banging head, etc.)
• If you are feeling unsafe, what are some things that you should have access to?
• Do any of your friends know that you engage in self-injury, and do any of them engage in self-injury?

(Franzen, M., Keller, F., Brown, R. C., & Plener, P. L., 2020).

Here are some example questions to ask during the assessment and safety planning process. I like to ask, "Are you having any thoughts of harming yourself?" If the therapist is uncomfortable asking the question, the client can sense this and might not be as comfortable sharing. This is where I think normalizing it is imperative. And if the therapist is not comfortable working with somebody that does engage in self-harm, refer the client to somebody that is equipped. If you are taking this training, I believe you want to feel more comfortable working with clients with these thoughts.

Other questions to ask are, "Are you having thoughts about dying or not wanting to be here?" and "Have you ever harmed yourself in the past?" We also want to lower the shame associated with self-injury. We may need to ask more specific questions or give examples because they may say no, they do not self-injure but do something like pull out their eyelashes or engage in other behavior.

We need to take some of the shame out of that from a clinician's perspective and ask questions such as, "If you are feeling unsafe, what are some things you shouldn't have access to? "This is part of the safety planning when the client is calm. The person may say something like a razor, knife, et cetera, and those are the things that I want to make sure to safety plan around.

We will discuss this more, but if somebody wants to engage in self-harm, it is hard to protect them from everything. I have had people self-harm with pencils. In the school system, they had an accommodation where they used pens while we worked on getting them to a safer place. But, they could get a pencil from a peer. We need to assess their method and access and make a safety plan.

I also like to ask if any of their friends also engage in self-harm. Peer groups will often talk about it. It can be supportive, where a friend can talk another friend out of doing it, or it can be triggering. Thus, a safety plan can include that if one of their friends talks to them about engaging in self-harm, ways they can then protect themselves. Make sure to include adults in the safety planning process, so that young kids or teenagers are not feeling emotionally responsible for one another. We can assess many behaviors by asking some of these questions.

Reasons Why People Engage in NSSI

• Self-injury ALWAYS serves a purpose for the individual. We need to LOCATE their PAIN.
• Important to understand the function of the behavior before removing the negative coping:
• Distraction (emotions, painful memories/thoughts, environmental issues)
• Manage Emotions (emotional numbing, or to feel when they feel numb)
• Self-punishment
• Control-maintain control or feel control over their minds and bodies

(Hooley, J. M., Fox, K. R., & Boccagno, C. 2020; Laye-Gindhu, A. & Schonert-Reichl, K.A., 2005; van der Kolk, B.A., Perry, J.C., & Herman, J.L., 1991)

Again, it is crucial to understand the why behind NSSI. Sometimes the person might not know. In general, self-injury is always serving a purpose for the individual. There is a reason for this behavior, whether they are using their frontal lobe and are aware of it, or it is a survival response triggered in the amygdala, as a fight, flight, or freeze response.

It might be more of a survival response, but we want to locate their pain because the behavior will not go away, or if the behavior does go away, they may replace it with something else that might be more harmful. For example, they may be at a higher risk of using substances or engaging in risky behaviors. And so being able to help locate that pain is significant.

Before removing this negative form of coping, I want to add something like a distraction. It might distract from negative emotions, painful memories or thoughts, or specific environmental issues. I have had many clients who self-harm if their parents argue. Adults may do so if they have a conflict with people and may use it to help them calm down.

It can be a way of emotionally numbing yourself. When we talk about parent education, I may dig a little bit deeper into the fact that engaging in self-harm can have a numbing effect on people. This can help me to figure out what tools this person might need.

For some people, it is about self-punishment. Non-suicidal self-injury often correlates with low self-esteem, negative thoughts about their body, and body dysmorphia. They may have a distorted perception of their body. Others may use it as a way to control their emotions.  

• Express things that they cannot put into words (emotions, feelings of loneliness/misunderstood/isolation)
• Relieve tension and/or anxiety
• Relieve and/or fully express a negative emotion (e.g., anger, depression, etc.)
• To feel real by feeling the pain or seeing the injury
• Purify self
• Punish self
• Nurture self or receive nurturing
• Boredom
  • Often more of a cycle than linear behavior

(Hooley, J. M., Fox, K. R., & Boccagno, C. 2020; Franzen, M., Keller, F., Brown, R. C., & Plener, P. L., 2020).

For some people, it is a way to see or express things they cannot say. You cannot see depression on someone's body or if somebody has been through a lot. A trauma survivor may not have a physical mark, especially for something emotional. It is a way to see their pain, and that gives them relief.

Self-harm behaviors can also relieve tension or anxiety or fully express a negative emotion like anger or depression. Emotions can get so big, and engaging in this behavior helps them come back down.

Self-harm may help someone feel real. I see this a lot with individuals who also have dissociation, who are kind of disconnected. They can be at a higher risk of self-harm, especially when in a dissociative or disconnected state.

It can be a way to purify or punish some unrelated to a spiritual or religious ceremony. It is a way of acting out self-hatred or that shame within themselves. For some people, it is a way to get nurturing from somebody else. 

One that is most surprising for people is boredom. If somebody already engages in this behavior, thoughts of self-harm might get very strong if they are bored. We may recommend that they are not alone when they are bored. They need to be with family or go somewhere. You can make an activity jar with ideas for when their thoughts get dark. With non-suicidal self-injury, it is often that cycle where the person engages in the behavior, stops for some time, is triggered, and starts again. This cyclical behavior can be very frustrating for parents. We need to educate parents that this is normal behavior.

Comorbid Presenting Issues

• Low self-esteem and feelings of shame/worthlessness
• Trauma and dissociative symptoms/disorders
• Relationship problems and/or bullying
• Less dense social networks
• Mood Disorders/Depression/Anxiety
• Psychosis
• Mood Disorders
• Substance Abuse
• Borderline Personality Disorder

(Hooley, J. M., Fox, K. R., & Boccagno, C. 2020; Franzen, M., Keller, F., Brown, R. C., & Plener, P. L., 2020).

Some comorbid presenting issues are pervasive, like low self-esteem and feelings of shame and worthlessness. An intervention would be helping them build their self-esteem and address their shame and worthlessness. The behavior will continue or worsen if I do not address these issues.

Research has also shown that trauma and dissociative disorders and symptoms are common. Self-harm might have been a way that they coped with a situation they did not have control over. After the trauma has ended, they might still engage in the behavior as a survival technique and response. For some, it can be hard to let go of because they might feel safer when engaging in self-harm. Thus, addressing that sense of safety can be incredibly important.

Relationship problems or bullying are also widespread. People take that stress out on themselves. Parents must be mindful of what is happening on social media or within certain text groups. Cyberbullying can be relentless. Twenty years ago, bullying was mostly at school or in your neighborhood, but now with kids having access to phones, the bully can have unlimited access to them. Parents need to set up certain safety precautions. Every state is different. I worked with some clients who had to do "no contact" agreements with a particular student or where we encouraged them to block specific numbers as they were not engaging in a safe and healthy relationship.

For individuals that engage in non-suicidal self-injury, research also shows that they typically have less dense social networks and are in a group of lower emotionally functioning individuals. Often in a lower-functioning group, other individuals within that group are also engaging in similar behaviors. With clients that present with non-suicidal self-injuries, I always want to know about their friends. We want to connect with them with other healthy peers at some point if we can. Again, we do not want to take away those people because it might be all they have, but we also want to try to add in some healthier people to expand their network.

Mood disorders, depression, anxiety, and psychosis are prevalent with non-suicidal self-injury. We also see substance abuse, either people using when they have the urge to use or possibly engaging in the behavior while using. I have seen it both ways. Sometimes with cannabis, I will see people not engage in the behavior when they are using, and then for other substances, they might be more likely to engage in the behavior while using.

As I mentioned earlier, a borderline personality disorder is common. I view that diagnosis as an inability to manage emotions and a skills deficit. Dialectical behavior therapy helps the person break some black-or-white thinking and address some underlying attachment issues. Fear of rejection or being left can sometimes trigger thoughts or engagement in non-suicidal self-injury.

Safety Planning (Harm Reduction)

• Identify an adult that the client will tell if they are having thoughts of self-injury
• Discuss if anyone else in the client's friend group engages in self-injury and encourage client/family to set boundaries in those relationships
• Identify what things the client should not have access to when upset
• Door open when upset
• Typical safety planning (lock up sharps)
• Identify their positive coping and discuss the times they are able to abstain from self-injury

(Dickens, Geoffrey & Hosie, Leah, 2018)

With safety planning, we take a harm reduction approach. In the next slide, we will talk more about educating clients, parents, and families, but with a harm reduction approach, the goal will always be zero self-harm. However, if I am working with somebody currently engaging in the behavior four times a week, I want to see that number or urge to engage in self-harm to be reduced. I also want to know if they have used skills because I want the client to feel some success along the way. I also do not wish to villainize them if they engage in the behavior.

Many clients will talk about non-suicidal self-harm as feeling like an addiction. If a client uses that language, I also use it with them. First, we want to identify an adult the client can tell if they have these thoughts. And whatever adult that is, I want to prepare that person to support the client, as some things can help and others can worsen it. I say an adult because kids going to kids or teens going to teens can be very triggering for the other individual. 

Discuss if anyone in the client's friend group is currently engaging in it, and then set some boundaries within those relationships. I have seen a teen dumping their problems on another without checking in to say, "Hey, are you in a good space where you can hear this?" Setting some emotional boundaries with their friends can be incredibly important.

Identifying what things the client should not have access to when upset is part of safety planning. Something that I have commonly instituted, especially for kids and teens, is if they are upset, their door is open. So if they go upstairs fuming and upset, they must leave the door open.

The next one is part of typical safety planning. We need to lock up sharp objects to help increase safety. I continually reaffirm that this is about safety and is not to punish them or because they did something wrong. What things do they already possess? Even within an initial session, if somebody is engaging in self-harm, I also want to hear about a time they had that thought and did not do it. We want to help them feel resilient and capable. You can also discuss how it may have been different at other times. They may have been under too much stress or were hungry and not sleeping well. These things can pile up. Identifying positive strengths within this individual can be so impactful as they are often very hard on themselves with some perfectionism and rigid thinking. 

Educating Clients, Parents, and Families

• Reviewing the myths, facts, and common reasons why other people engage in self-injury
• Start from place of understanding why and locating the pain (often families only want the behavior to stop)
• Addictive Quality
• Appropriate emotional expression (often comes from overly expressive or invalidating environments)
• Skills deficit versus manipulation

(Dickens, Geoffrey & Hosie, Leah, 2018; Nielsen, E., Sayal, K., & Townsend, E, 2017)

When educating clients, parents, and families throughout this process, I want to review some myths and facts about self-harm and common reasons why people engage in it. One of the biggest things I like to do is explain its biology. When we harm ourselves, our body releases happy thoughts. For example, if I fall and hurt my knee, my brain's coping mechanism is to release happy thoughts. Parents often struggle with this concept and do not understand how their children can do this. I do this in a one-on-one session with the individual and the parents because unless you have a good sense that this would work well, I will avoid doing it as a family session. I want the parents to ask certain questions to help them not react when the person does come to them with these thoughts or behaviors. Then we make a plan. I often encourage them to fake it. "You will be freaking out, but if you freak out on the outside, it will make them feel unsafe in the moment."

It is essential to get those needs met. We want the parents to start from a place of understanding and locating the pain. Families often want the behavior to stop, and that is where I explain that stopping the behavior may allow another negative response to occur. There is something under this, and it is not just a phase. Some people grow out of it, but others do not.

It can have that addictive quality that I mentioned earlier. A person can get into the cycle of use. People will talk about being clean from self-harm for three months, four months, or only one day. If they do like that addictive quality, language that is used in substance abuse treatment can be helpful. You want to help them find other ways to express their emotions.

They may come from environments where emotions are expressed in very big ways, and they may feel like their feelings are getting too big. Or they may come from an invalidating environment where emotions are seen as dumb or weak. We can teach parents, families, and clients how to validate their emotions. Depression and emotions are not good or bad; it is what we do with them. We want to talk about it from that perspective.

I also like to educate on the difference between a skills deficit versus manipulation. 'Parents may say they are being manipulative. I see manipulation as trying to get your needs met in inappropriate ways. It is always about a need, but they are not going about it correctly. Let's teach them healthier ways to get those needs met.

• Severe and Most Common Risks
  • Infection
  • Link between self-harm and suicide
  • Accidently harming self more than intended/lethal
• To hospitalize or not hospitalize (psychiatric) 
  • Clinical decision with client, family, and mental health provider
  • Consider potential for increased negative behaviors in psychiatric hospital
  • May require medical attention if significant physical injury
• Help client and family set appropriate boundaries

(Donath, C., Bergmann, M. C., Kliem, S., Hillemacher, T., & Baier, D., 2019; Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., ... & Green, K. L., 2018; Lloyd-Richardson, E. E., Lewis, S. P., Whitlock, J. L., Rodham, K., & Schatten, H. T., 2015).

The severe and most common risk with non-suicidal self-injury is infection. There is also a link between self-harm and suicide that has been shown in research. There is a difference between somebody that is practicing, trying to get used to the sight of blood, to be able to then complete a suicide versus somebody that is engaging in self-harm as a way to cope with emotions. The latter group has plans for the future. Another risk is that they might accidentally harm themselves when they did not intend to do so.

To hospitalize or not hospitalize is a clinician's decision with the client, family, and other mental health providers. Considering the potential for increased negative behaviors in the psychiatric setting is crucial. I have had clients go into psych hospitals for short-term stabilization and come out way worse. They learn new behaviors and connect with very low-functioning peers. We need to weigh if there is a way to maintain them at home safely. But if they require supervision or medical attention, a psychiatric stay may be appropriate. Individuals might also require medical treatment if they have a physical injury from engaging in the behavior.

We want to help the client and family set appropriate boundaries. I have seen a very entangled family where the child was taking on the parent's emotions and vice versa. We need to set some emotional boundaries.

Addiction

• Although there is conflicting research about whether non-suicidal self-harm is a behavioral addiction, many clients will describe it as addictive.
• Possible Treatment Interventions
  • Motivational Interviewing
  • 12 Steps
• Harm Reduction instead of harm elimination

(Blasco-Fontecilla, Hilario & Fernández-Fernández, Roberto & Colino, Laura & Fajardo Simón, Lourdes & Perteguer-Barrio, Rosa & de Leon, Jose, 2016)

When looking at self-harm through the lens of addiction, there is conflicting research about whether non-suicidal self-harm is a behavioral addiction. Many clients describe it as addictive, so some possible interventions might be motivational interviewing. A client may not intend to stop the behavior or see anything wrong with it. They may be seeing you because their parents want them to be there. With motivational interviewing, I want to take them through those stages of change. In the example, the individual is pre-contemplative and does not view their actions as a problem. There are also 12 steps programs if they identify with the language. Harm reduction versus harm elimination may also work.

The goal is always for the behavior to stop, but knowing it will be a process. We want them to reduce the harm by drawing with Sharpie where they would like to harm or using less harmful things like ice. Once again, they do less harm and not to the point where they are causing damage to the skin. The practitioner will partner to see what will work best for that client as it will differ between clients. It is partnering with them and saying, "Through this process, I might recommend something. It might not work, but we are going to keep trying. I have a lot of tools in my toolbox, and I will be able to support you in stopping." This is about their behavior, and they have to want to stop. In the resource section, there is a book that supports this message.

Grounding Techniques

• Trauma symptoms, including dissociation
• Examples of Grounding Techniques
  • Using the Senses: 5 Things you see, 4 things you feel, 3 things you hear, 2 things you smell, and 1 thing you taste
  • Butterfly Technique (also works with other animals, images, or name of someone in their family they care about)
  • Apps (e.g., Calm Harm)

(Grattan, R. E., Lara, N., Botello, R. M., Tryon, V. L., Maguire, A. M., Carter, C. S., & Niendam, T. A.; 2019)

An intervention that can be helpful is using grounding techniques. If a person feels emotionally overwhelmed, doing some grounding technique can often help them self-rescue and calm down. One example is using the 5, 4, 3, 2, 1 technique using the senses. I often explain to clients that the thinking brain is shut down when they are emotionally activated. We can calm the amygdala, the emotional part of the brain, by using our senses. This is where grounding techniques can be helpful, especially for individuals that have trauma symptoms like dissociation. The butterfly technique is where you fold your fingers, put your hands together, and tap back and forth like a butterfly hug. Another butterfly technique is where the client draws a butterfly or something on the place where they want to engage in self-harm. They can also use the name of a person that they care about in that spot. This externalizes it because the person will often not mind hurting themselves, but they do not want to hurt others or are protective of others. Some apps can be helpful. My clients have found the best apps, but Calm Harm is one example by the same company that does the Calm app. 

Dialectical Behavioral Therapy

• DBT was Developed by Marsha Linehan
• DBT Skills Training
  • Mindfulness Skills
  • Emotion Regulation Skills
  • Distress Tolerance Skills
  • Interpersonal Effectiveness Skills
• Full DBT program
  • Individual therapy, Group Therapy, & Crisis intervention

(Kothgassner, O., Goreis, A., Robinson, K., Huscsava, M., Schmahl, C., & Plener, P., 2021)

https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/

Dialectical Behavioral Therapy, DBT, was developed by Dr. Marsha Linehan. The skills training includes mindfulness, being present in the moment, regulating emotions, and distress tolerance. DBT also means being less judgemental of yourself and looking at facts versus our perception or interpretation of things. It also includes interpersonal effectiveness skills. The ones I have taught the most are mindfulness, emotion regulation, and distress tolerance.

Skills training is very different from a full DBT program. Some individuals need a full DBT program that includes individual therapy, group therapy, and crisis intervention, where if they are feeling suicidal, there is a therapist on call to be able to support them in those moments.

Other Types of Treatment

• Cognitive Behavior Therapy
• Applied Behavior Analysis (individuals with autism, developmental disorders, or intellectual disabilities)
• Eye Movement Desensitization and Reprocessing (EMDR)
• Psychotropic medication (refer to a psychiatrist or discuss concerns with a medical doctor)

(Bahji A, Pierce M, Wong J, Roberge JN, Ortega I, Patten S., 2021; Gonzales AH, Bergstrom L, 2013)

Other types of treatment are cognitive behavior therapy and applied behavior analysis (ABA). ABA might be helpful if an individual has autism developmental disorders or intellectual disabilities, but we want to replace it and find ways to calm the individual. One example is an individual banging their head, but now there is a pillow. We are gradually shifting the behavior to something that is not causing harm. Eye Movement Desensitization and Reprocessing (EMDR) can be helpful for this. Lastly, we can refer to a psychiatrist or medical doctor for a medication evaluation and psychotropic medication if needed.

Resources

• Free guide through SAMHSA Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-06-01-002.pdf
• Treating Self-Injury, Second Edition: A Practical Guide Second Edition by Barent W. Walsh  
• Helping Teens Who Cut, Second Edition: Using DBT Skills to End Self-Injury by Michael Hollander  
• Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones 1st Edition by Janis Whitlock, Elizabeth E. Lloyd-Richardson 
• Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by Paul T. T. Mason MS, Randi Kreger 
• Stopping the Pain: A Workbook for Teens Who Cut and Self Injure by Lawrence E. Shapiro PhD 
• Non-suicidal Self-Injury, in the series Advances in Psychotherapy, Evidence Based Practice by E. David Klonsky, Jennifer J. Muehlenkamp, et al. 
• Freedom from Self-harm: Overcoming Self-Injury with Skills from DBT and Other Treatments by Kim Gratz, Alexander Chapman, Barent Walsh (Foreword)

Here are some additional resources. There is a free guide through SAMHSA called Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts in Youth. I also mentioned the book, "Helping Teens Who Cut: Second Edition Using DBT Skills to End Self-Injury," and the other is stopping the pain. It is a workbook that I have frequently used. I always keep a list of resources to see what is a good fit for your clients. "Stop Walking on Eggshells" can often be a helpful book for teen clients and parents to set boundaries. 

Summary/Review of Learning Outcomes

Thank you so much for attending this training. My goal is that you now know how to explain non-suicidal self-injury, discuss different types of self-injury, and dispel common myths about it. I also want you to identify ways to assess for non-suicidal self-injury and have a safety plan. And then lastly, I hope you can identify clinical approaches to consider when treating non-suicidal self-injury.

Online References

• https://health.usnews.com/health-news/health-wellness/articles/2014/12/26/myths-and-facts-about-self-injury
• https://www.healthyplace.com/abuse/self-injury/10-ways-people-self-harm-self-injure
• https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/
• https://safeharborhouse.com/what-we-treat/co-occurring-disorders/self-harm/

References

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Blasco-Fontecilla, H., Fernández-Fernández, R., Colino, L., Fajardo Simón, L., Perteguer-Barrio, R., & de   Leon, J. (2016). The addictive model of self-harming (non-suicidal and suicidal) behavior. Frontiers in Psychiatry, 7.

Dickens, G. & Hosie, L. (2018). Self‐cutting and harm reduction: Evidence trumps values but both point forward. Journal of Psychiatric and Mental Health Nursing, 25, 10.

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Franzen, M., Keller, F., Brown, R. C., & Plener, P. L. (2020). Emergency presentations to child and adolescent psychiatry: Non-suicidal self-injury and suicidality. Frontiers in Psychiatry, 10, 979. https://doi.org/10.3389/fpsyt.2019.00979

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Grattan, R. E., Lara, N., Botello, R. M., Tryon, V. L., Maguire, A. M., Carter, C. S., & Niendam, T. A. (2019). A history of trauma is associated with aggression, depression, non-suicidal self-injury behavior, and suicide ideation in first-episode psychosis. Journal of clinical medicine, 8(7), 1082.

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