Treating Non-Suicidal Self Injury

Editor’s note: This text-based course is an edited transcript of the webinar, Treating Non-Suicidal Self-Injury, presented by Patrice Berry, Psy.D, LCP

Learning Outcomes

• Define non-suicidal self-injury, different types of self-injury, and dispel common myths about self-injury
• Identify ways to assess for non-suicidal self-injury, safety plan, and common reasons why people engage in this behavior
• Identify clinical approaches to treating non-suicidal self-injury

Introduction

I'm a clinical psychologist and I've been working in the field for over 15 years. I started in residential treatment and throughout my work, I've seen an increase in non-suicidal self-injury (NSSI) and thought this would be a good course for people at a variety of levels. Learning how to address non-suicidal self-injury applies to work within school systems as school social workers will get referrals when there is a report of a student that's been engaging in behaviors. If you're working within the juvenile justice system, either adult or at the pediatric level, you may see this type of behavior come out. This is also common in medical settings/hospital settings such as the ER, community-based programs, outpatient clinics, and residential/group homes. 

Disclaimer

Some of the treatments talked about in this presentation require additional training and this training will not cover everything that's involved with those programs.  If you find something that you're really interested in, I'd encourage you to get additional training or certification. For example, we'll be talking about some dialectical behavioral therapy programs and skills, and that maybe something that you want to look into more in the future.

Mental health professionals are responsible for operating within our scope of practice. If you do get a case that you're not comfortable treating within your practice, or if there's something that's outside of what you're used to dealing with, I would encourage you to refer to an appropriate person or seek appropriate consultation. 

Terms Defined

There are lots of different terms that are used and when you're doing a risk assessment, we will assess for suicidal ideation.

Suicidal Ideation is thoughts of wanting to die. We often differentiate that from a suicide attempt. If someone has actually acted on those thoughts, we would consider that to be a suicide attempt.

Thoughts of self-harm are defined as thoughts about harming yourself and some people just have thoughts about harming themselves with no intent to die. 

Non-suicidal self-injury would actually be acting on those thoughts of self-harm. In this course, we'll be talking about dealing with non-suicidal self-injury, actually acting on those thoughts, and how we can help clients cope with having thoughts of self-harm. 

Types of Self-Injury Examples

There are many different ways that individuals can engage in self-injury. The most common is cutting and it is the one you'll often get a referral for. You might get a call from a parent or a call from a concerned family member that someone is engaging in cutting.  I just wanted to give a list of a lot of different types (shown below) because all of these behaviors are definitely concerning and we would want to do a further assessment if someone is engaging in these types of behaviors. We wouldn't want to ask are only engaging in cutting. We would want to get an idea of what are the other ways or types of things an individual is engaging in self-injury. 

Some individuals scratch themselves and it's not because they itch, it's for the purpose of doing harm. Headbanging is very common, especially in individuals that maybe are on the autism spectrum or in younger kids in general as well. Pinching is another type and that would be pinching themselves to the point of doing some type of harm. In all types of self-injury, it's doing deliberate harm to oneself. Hair-pulling (trichotillomania-term within your DSM5) may include pulling eyebrows, pulling physical hair, or pulling the hair on someone's arm.

Biting nails to the point of bleeding is another example of self-injury. This would be going beyond just being nervous biting nails. It's being emotionally distressed and then engaging in some nail-biting. Punching self or punching objects is one that I think sometimes gets overlooked.  Punching self or punching objects can be a form of self-injury where someone gets so mad to the point that they punch a wall and then they feel better.

Carving words or images into the skin is another form of self-injury. All of these behaviors are for the point of relieving some type of emotional distress or relieving some type of pain. Exceptions to this would be those that are considered to be spiritual rituals culturally or someone that gets a tattoo to remember a person after that person has passed away.  It would only be self-injury if the point of the behavior was to cause some type of pain in order to relieve that distress.

Burning, rubbing sharp objects, teeth pulling, eating sharp or dangerous things, putting needles or objects under the skin, breaking bones, or intentionally reopening wounds are other examples of self-injury and definitely becomes a safety risk that you'll also want to assess. 

• 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
• Putting needles or objects under the skin
• Breaking bones
• Intentionally reopening healed wounds

Special Note

Within the DSM-Five, NSSI is listed as a condition requiring further study. That would be someone that is only engaging in these behaviors and they don't meet the criteria for depression or anxiety, or an eating disorder, substance abuse, or some other trauma-related disorder. In my years of practice, I've never had someone only have non-suicidal self-injury.  There have typically been other things going on, but I've worked primarily within clinical settings where someone was coming with a variety of other things. Non-suicidal self-injury is also a very common symptom with Borderline Personality Disorder, along with suicidal self-injury, suicidal gestures, or suicide attempts. 

Common Myths About Self-Injury

There are lots of common myths about self-injury. 

• 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

Facts About Self-Injury

• Self Injury is common, especially among adolescents
• Self-injury does not mean that a person is suicidal
• Self-injury is often hidden and is a private act, it is always a negative way to cope
• Individuals can have NSSI one day and suicidal ideation another day
• There are multiple documented forms of self-injury
• Tattoos and piercings are only self-injury when used as a way to cope and not just personal expression
• Self-injury can become addictive and yet there are multiple effective treatments.  

Self-injury is actually really common, especially among adolescents. It can begin as early as maybe five or six years old and it's often a way to try to cope or deal with emotions, with internal distress. It can continue all the way up through adulthood. Some recent studies have shown that maybe a third of adolescents have engaged in some type of non-suicidal self-injury. Some people try it and they don't like it.  Others engage in the behavior and then it becomes a negative way to attempt to cope with things in their life.  That is when they're often going to need some type of treatment to replace that behavior with something that's healthier. 

Self-injury doesn't always mean that the person is suicidal. It could mean that they just had a bad breakup and they engaged in the behavior as a way to cope with the problems. We don't want to think, "Oh, it's not that bad." because it's not suicidal.  We don't want to minimize the behavior because they didn't have thoughts to die, but at the same time, we don't want to overreact to the behavior if the person just needs different ways to cope with what's going on.

When people think that self-injury is about attention, that goes against the fact that self-injury is often hidden; people often do it in areas that aren't seen. It's very common for the bathing suit areas, upper thighs, and maybe the stomach. Within my practice, if someone has injuries that are within certain parts, I encourage the family or a medical doctor to take a look at where those injuries might be.  As a clinician I say I look for maybe cuts on arms. If I do see a cut on a client, it's just natural to check in with them to see, "Hmm, so what happened?" Having an inquisitive, "Oh, I noticed that." and not a judgemental tone because they're often more likely to talk more about what's going on if they don't feel judgment coming from the social worker.

Self-injury is always a negative way to cope. If the individual had a better way to deal with their emotions and behaviors, (and I've been doing this work for a long time, trust me) they would do it. Typically, these are individuals that don't manage emotions very well. Maybe within their family, emotions are either overexpressed where emotions are just are these big volcanoes that are constantly erupting or maybe they're in a family where emotions are never expressed and they're minimized. They haven't learned appropriate ways to cope with and deal with emotions. Knowing what's under the self-injury will help direct your treatment or your recommendations for the client or the family. 

Individuals can have non-suicidal self-injury one day and then potentially have suicidal ideation another day, or maybe even within the same day. Just because someone engages in non-suicidal self-injury doesn't mean that they don't have suicidal ideation too. Therefore, you want to assess for both and that will direct your risk assessment and your recommendations once you've determined with the client and the family what next steps you need to take.

There are multiple documented forms of self-injury, which was discussed earlier. Tattoos and piercings are only self-injury when they're used as a way to cope and not as a form of personal expression. Self-injury can become addictive and yet there are multiple effective treatments. We will get more into the addiction model that sometimes is associated with self-injury a little bit later. 

Example Questions During Assessment and Safety Planning

Below are just some example questions that you might ask during a risk 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?  

If the client says "yes" when asked if they are having thoughts of self-harm, you want to follow up with, “in what ways”? You want to get the idea of the frequency of these thoughts if they are engaging in any type of behavior.  Be very straightforward in asking those questions. As a social worker especially you need to manage your reaction to those questions because clients are good at picking up other peoples' reactions and emotions. You need to stay neutral throughout that assessment process because sometimes if you have a big reaction or if the client can tell that it's upsetting you, then maybe they'll stop talking.

There are some clients that don't get attention in an appropriate way. That's the way I like to reframe manipulative behavior or attention-seeking behavior because this is someone who needs attention, but they're going about getting it the wrong way. There are some clients that if they know they're getting a reaction, may escalate things a little bit more and so the social worker managing their reactions during this can be very helpful. 

Ask your client if they are having those thoughts of dying or have they ever harmed themselves in the past and then giving examples to maybe lower the shame. Have you cut? Have you hit things? Have you banged your head? That is a way to get an idea from the client of what ways they've harmed themselves in the past.

The question regarding asking the client if you're feeling unsafe and what are some things they should not have access to should be asked when the client is calm and in a positive space. They will be more likely to give you good information. For example, "Oh yeah, so when I am upset I pens, so I don't need to have access to pens because I'll break them.

You will notice as a clinician that it can be very difficult to safety plan with someone when they want to harm themselves because often people can be very creative in finding things.  That's where partnering with the families and/or partnering with whatever setting they're in to try to promote safety is very important. Often clients want to learn new skills because the scars can sometimes be a negative reminder to them. Some people are triggered by their scars. It is important to find ways to partner with them and get an idea from them of what maybe they shouldn't have access to if they're not feeling safe. Ask them if they have any friends that engage in self-injury because often individuals that are engaging in this type of behavior come from a friend group that maybe is lower functioning emotionally and may have other friends that are also engaging in this type of behavior. I found it helpful to get an idea of who do they want to talk to when they're feeling that way and who talks to them if they're feeling that way because often that can trigger the individual that you're working with if someone else is having thoughts of self-harm. That client may talk them through it, but now they're feeling triggered to self-harm. I've often encouraged, especially when working with teens or kids, if someone does reach out to them having those thoughts, letting that friend know that they're going to have to notify an appropriate adult to make sure that when they themselves are already struggling with managing emotions aren't having more than they can actually handle. 

Reasons Why People Engage in Non-Suicidal Self-Injury

If you don't get anything else out of this course, this is the one thing that I want to make sure that you all get. Self-injury always serves a purpose for the individual and the best treatment is going to be to locate the source of that pain. In our work, if we get them to stop the behavior without locating their pain, they will replace it with something else. They'll replace it with substances or they'll replace it with risky behaviors because they're going to try to find a different way to cope. 
It may be in midst of a conflict that triggers negative self-talk. If we can increase his or her ability to tolerate that conflict or help him or her strategize around those situations, that's often one of the best things that can help with this type of behavior. For example, when difficult conversations do happen, if the family can be mindful of this client's emotions or if it's an adult and they know when they get negative feedback from their boss, that's a trigger, that will help. 

In psychoeducation with families or with loved ones with non-suicidal self-injury, I like to explain the biology of it because often they don't get it. They don't understand why someone would hurt him or herself. That's when they say words like, "That's crazy," and that's where you, being the professional come in and say, "Well actually, when we hurt ourselves the body releases endorphins, and those positive thoughts actually do make you feel better. If our bodies didn't work that way, "we would die from a paper cut." So when someone does hurt themselves, the body does release endorphins, and sometimes people have a high tolerance for pain or they build up a tolerance for pain. Educating families helps them understand what's going on can often help them support the individual they're working with.

Sometimes families will think it's just a phase. They may think it is something they do at 12 or 13, but for some people, it's actually more of a cycle than linear behavior where you start and then stopped. For some people it's okay, they start, and then they don't engage in behavior for two or three months. Then they start the behavior again and then they stop for six months. The behavior starts again and becomes more of a cycle for some people. For a lot of people, the thoughts continue. So even if they stop engaging in the behavior, the thoughts may come and go. I have one person that I check in with because those thoughts come when they're stressed. They're still in high school and we usually meet once a month, but around exam time we meet twice a week or we might meet once a week. They're not engaging in the behaviors, but coming to sessions helps when they've had an increase in stress.

It's important to understand the function of the behavior before removing this negative coping skill. 

Distraction

Sometimes it can be a distraction from emotions, from painful thoughts or memories, and/or from environmental issues. This is very common with homes that have high conflict or relationships with high conflict or with trauma survivors. For individuals that are experiencing flashbacks or if they're triggered in some way in their environment, self-injury may be a form of distraction.

Manage Emotions

Self-injury may be a way to manage difficult emotions. For some people, it's when those emotions get to a place that they can't manage. They might engage in this behavior to ground themselves and to help them get back to a more stable place, or some people if they're not feeling anything, might engage in the behavior to lift up emotionally. 

Self-Punishment

For some people, self-injury is a form of self-punishment. That's very common with individuals with very low self-esteem, very low self-worth, a lot of guilt and shame. If we know this is what's under the behavior that'll direct our treatment.

Control

For some people, it's about control. It's about being able to control.  "I can't control what school I go to or what family I'm in, but I can control engaging in this behavior." 'Often people will feel that there is no one that can make them stop the behavior and so if I know it's about control, (which is also very common with eating disorders and sometimes with trauma) finding other ways for them to have appropriate control might be an intervention that I would use with an individual like that.

Express Things That They Cannot Put Into Words

It may be a way to express things that they can't put into words. For example, you may see someone talk about seeing the mark or seeing the blood or seeing what happened was a physical expression of an emotion or of things that they could not put into words. Depression, anxiety, and loneliness aren't things other people can always see and so sometimes people want a physical representation. 

Relieve Tension and/or Anxiety

It may be a way to relieve tension or anxiety.

Relieve and/or Fully Express a Negative Emotion

It may be a way to relieve or fully express an emotion like anger or depression

To Feel Real by Feeling the Pain or Seeing the Injury

For some people, they may describe it as a way to feel real. It is similar to that of emotional numbing. It is very common with trauma survivors when they're having disassociation; when they're disconnecting from reality. Sometimes I've heard clients say that they almost feel like they're coming outside of themselves and self-injury helps bring them back to their body. We will talk later about grounding techniques and finding healthier ways to help them feel real can be very helpful.

Purify/Punish Self

Some people along with punishing themselves might talk about self-injury as a way to purify themselves. I had one situation where the person felt it was part of their religious expression. In talking with their family that was of the same religion, the family was like, "No, that's not a way." The person was using scriptures and focusing on the punishment part, but that wasn't even within their religion. Their religion wasn't telling them to harm themselves. If you are working with someone and if there is a question of whether this is a religious thing, you may get a release to partner with their religious leader or with their family so you can check in to see if this is a common thing within their religious expression. 

Nurture Self or Recieve Nurturing 

It may be a way for them to nurture themselves or to seek nurturing or support. For example, having to clean the wound or seeking help from someone may be a way that they're seeking their assurance.  We would try to find better ways to have them get that need met.

Boredom

Nothing to do can be a big trigger and that all of a sudden thoughts come up and then they engage in the behavior.  For those individuals, sometimes we've done a "bored jar" where we take a jar and fill it with things you can do when you're bored. If it was a behavior they would not engage in when they are by themselves, we can encourage them that when they get bored to go be around other people.   

Comorbid Presenting Issues

Comorbid presenting issues with non-suicidal self-injury:

• 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

It's very common to see low self-esteem, feelings of shame or worthlessness, a history of trauma and/or dissociative symptoms, or dissociative disorder along with NSSI. Individuals that report relationship problems or possibly bullying are also common presenting problems to go along with self-injury. They tend to have those less dense social networks that were mentioned before where maybe all of their friends or a lot of their friends also engage in this type of behavior. Other common presenting issues include mood disorders, depression, bipolar disorder, disruptive mood dysregulation disorder, depression, and anxiety.  Non-suicidal self-injury and suicidal self-injury are very common within Borderline Personality Disorder.

Psychosis is also a common comorbid presenting issue with NSSI. With psychosis, I'd want to check to see if there are voices telling the person to engage in the behavior because of command auditory hallucinations. If they do have psychosis, are they hearing voices that tell them to harm themselves? For some people with psychosis, it's not that the voice told them to harm themselves. It's that the voice triggered thoughts of "you're nothing, you're not worth anything" and the voice triggered negative thoughts and negative emotion which then they engaged in NSSI.

If the person was not feeling as if they were in reality sometimes, people engage in non-suicidal self-injury. We want to find other ways for them to ground themselves if they were having those types of thoughts. Like mood disorders, substance abuse typically reduces inhibition therefore reducing the things that people wouldn't do sober but may do under the influence. Someone that's great about managing their thoughts when they're sober, under the influence they might be more likely to engage in that type of behavior.

Safety Planning

Identify an Adult that the Client will Tell if They are Having Thoughts of Self-Injury

If you're working with someone that is having these types of thoughts, you'll want to make sure that they're being monitored and that there's some type of safety plan in place. They need to identify a safe adult and if it's a child or teen, it'll have to be their parent. They might identify some additional adults because they may not have a great relationship with their parents. For example, they may have a good relationship with an aunt.  The child/teen will agree that if they're having those thoughts to reach out to the aunt. The aunt would appropriately support the family and would make sure that the parents are aware.

Discuss if Anyone Else in the Client's Friend Group Engages in Self-Injury and Encourage Client/Family to Set Boundaries in Those Relationships

The reason why I mentioned always using an adult versus another child or teen is that kids and teenagers want to tell a friend and that places too much on another peer, on another child. As I mentioned before, it is very common that a child/teen surrounds themselves with another person that has those similar thoughts. It may trigger him or her too and we are not always sure that a child will appropriately follow up with the family. Discuss if there's anyone else in the child's friend group that's engaging in this behavior and encourage the family to set appropriate boundaries within those relationships. That maybe they can continue those relationships, but setting up that, there's someone, an adult can be notified if maybe that friend is in a bad space. 

Identify What Things the Client Should Not Have Access to When Upset

Identify things that the client should and shouldn't have access to when they're upset by asking the client and family. 

Door Open When Upset

This is just mine that I typically use, a rule with families in crisis is if you're upset the door's open, just making sure that kind of, because typically people won't engage in behavior out in the open. Every now and then you will find individuals that do engage in the behavior at school in class, but it's more common in a private setting. Having the door open also makes it easier for the family to check on the client and to maintain appropriate supervision if they are upset.

Typical Safety Planning 

Doing those typical safety planning things, so Locking up sharps, weapons, knives all fall under typical safety planning.  If the client is in crisis, making sure they don't have access to the pins or whatever those things that they've identified they shouldn't need access to when they're upset.

Identify Their Positive Coping Skills

Have them identify their positive coping skills  What are those things that do work? 

Sometimes you'll get clients that say, "Coping skills don't work for me, "they don't work for me." I like to say that it has to match the size of your problem. For example, if I have something really bad happen in my life, deep breathing isn't big enough to fit the size of that problem. Sometimes just crying or talking with someone will work. Maybe there are certain things that will work with the size of that problem. Appropriately discuss with your client that it's not that the coping skill doesn't work, it's that maybe it didn't work in that situation. It wasn't the right fit for that specific situation and that takes some of the personal blame out of it (because often these clients already struggle with self-esteem and self-blame). The family may ask the client, "why didn't you use your skills?" It is important to figure out ways to help empower them in those difficult times. You want to be able to replace the behavior with something more positive because we don't want to take it away and then leave them with nothing.

Signs of Self-Harm

If you see any of these signs below, you just want to check-in and ask questions.

• Unexplained marks or injuries/bandages
• Long sleeves when it is warm outside
• Marks in private areas
• Covering wrists or forearms
• An injury does not match the explanation

When a client comes in and they have some band-aid or they have a mark that I can see I just say, "Hey, what was that?" If they keep having marks that are unexplained, I am then wondering if I am getting the whole story with this situation. For some people, another sign is wearing clothes that don't match the weather.  For example, wearing long sleeves even when it's warm outside. That doesn't always mean a sign of self-harm behavior because there are some places especially in schools, schools are cold inside but really hot outside.  If you're seeing it a lot, it's just something to follow up on, especially if the family is like, "Oh yeah, "we haven't seen their arms in weeks," or, "We never see this or that."

Family might report marks on private places or covering the wrist or forearms with some type of maybe band.  You may have clients that describe the injuries, but they don't match the explanation. For example,  you might see marks that look like they were done with some type of sharp object, but then the client says they ran into a wall.

Educating Clients, Parents, and Families

Review Myths, Facts, and Reasons Why

One of the first things that I like to do is educate the clients and families by reviewing the myths and facts of why people may engage in self-injury. If you Google "myths about self-injury," or "facts about self-injury," often there are some PDFs that were already created that you can have when you're working with these families.

Place of Understanding Why 

When issues like this do come up, you want to start from a place of understanding and from a place of curiosity such as "help me understand". Try to locate that pain because often, the families just want the behavior to stop. They feel the individual is in therapy so that they just stop the behavior.  Therefore, it's important to educate them that the first step is to figure out "why the behavior" because if we make them stop without understanding "why", we may end up dealing with something else down the road.

Addictive Quality

It is important to talk with families and clients about that addictive quality if they're experiencing that.  So clients do not.  The client may have done it a few times because their friends were or they did it to fit in with the friend group. Those are clients that will not need treatment for very long because they will often agree not to engage in the behavior again if they never have to come to therapy again. Those clients may not have those deeper issues and it was just a peer issue.

Appropriate Emotional Expression

Find an appropriate expression of emotion. Clients often come from overly expressive or invalidating environments.  If they're in a family where emotions aren't expressed appropriately, educating the whole family on emotional expression is needed.  Education should include that emotion is okay; we just don't hit, kick, scream, harm ourselves, and we don't harm others. There are times when we have to have that discussion with the family that are overly expressive.  For example, maybe when the parents get upset, they're also yelling, screaming, throwing things. Every now and then you'll have situations where a parent may also engage in self-injury, which is very concerning. It is important to figure out how to best support that family with the resources available to you within your community.

Sometimes clients come from invalidating environments where emotions are not allowed. Educating the family on validating emotions is important then. Sometimes I like to use a fun way to educate the family where I tell parents, "I don't know what's wrong with these kids, but I know something that works". Validating their experience is key. For example, when the child/teen comes home from school saying, "I've had a bad day," follow up with "Oh, what happened"? Instead of saying, "let me tell you about my day" and "I don't know how your day could be bad, all you did was go to school". That's invalidating language that then makes it, "Okay, well that day wasn't bad enough, how bad does my day need to be for me to get support?" Then that is where sometimes individuals start to exaggerate stories and catastrophizing because they're trying to get the family to say, "Aw, that stinks. Aw, you had a bad day, tell me more."

Skills Deficit Versus Manipulation

Talk about the behavior as a skills deficit versus manipulation. This is a reframe because if the family is viewing that it is manipulation, they will be extremely frustrated with the child or adult (whoever is engaging with the behavior). However, if you educate the family to look at it as a skills deficit, you can change their mindset to viewing it as, "This person "if they had the skill to get their need met, they would use it." This is where we just need to teach them a skill.

When viewing it as manipulation, parents are more likely to say, "Oh, you're just doing this because you want attention," instead of looking at it and saying, "okay, what are some more positive ways that we can help him or her get attention?" How can we teach the individual that they can get his or her needs met without engaging in these behaviors. This comes from the work from dialectical behavioral therapy that we'll talk about later in the course. 

Dangers of Self-harm

• The dangers of self-harm include infection. We may have safety planned at home, but someone at school could giving them sharps or other things they're also using to harm themselves which could lead to a risk of infection.
• There can be a link between self-harm and suicide. Just because someone is having non-suicidal self-injury doesn't mean that there is not a need for a referral of psychiatric hospitalization because maybe this is practice for thoughts down the road. 
• Assessing for self-harm and suicide can be important. Sometimes people can accidentally harm themselves more than they intended to.  This is why it is important to get them to reduce the behavior with the goal to eventually stop the behavior.   

To Hospitalize or Not Hospitalize

Clinical decision with client, family, and mental health provider.  The question of to hospitalize or to not hospitalized for psychiatric care is a clinical decision that's made with the treatment team as an outpatient provider, or if you're within a school setting you would seek consultation with your director. There are times that the person had non-suicidal self-injury and they contract for safety. The person comes from a very supportive family that can keep him or her safe; they have outpatient in place and then the recommendation may be to continue to maintain them at home.

On the other hand, there may be a situation that is more of a concern.  The client's behaviors have been escalating.  There may be non-suicidal self-injury, but there's also some psychosis.  The recommendation, in this case, would be to hospitalize. Each situation will be different. Hospitalization does not always occur if there is that non-suicidal self-injury because within psychiatric hospitals people are exposed to people non-suicidal self-injury.  I've had clients learn about self-injury in the hospital because they talked with their peers. 

Inquire about the media that they're watching and the effect that that media has on them. There are certain series that show self-harm, both suicidal and non-suicidal self-injury. Sometimes viewing that media can trigger clients and that's why when I'm working with clients I ask them, "What are you watching on Netflix? "What are you watching on Hulu or on TV?" Follow up to get more information. "How does that make you feel? "Does that trigger things for you?  For some people it does, for some people, it doesn't. Certain songs can sometimes help people feel better.  Educate the family that sometimes very dark depressing songs actually validates the client's emotions where the music makes him or her physically feel better. For example, I've listened to a song with the client if it was appropriate.  If it's an appropriate song, we sometimes listen to it in session.  It doesn't lift my mood, but for them, they connect with the song and they connect with the artist. Educate him or her to be mindful that on this day the music may work for you, but on a different day, it might not, and need to switch to something different. 

If there is a significant physical injury such as a deep cut or a broken hand, an Emergency Room visit may be warranted.  They will typically be assessed for mental health issues while they're at the hospital especially if they are going there after engaging in some form of self-injury. It will be up to the hospital staff if they admit them to the hospital or not. If you're part of that team that's where just consulting with the doctor, consulting with the team about the recommendations for that individual case. And then helping the client and family set those appropriate boundaries. 

Addiction Model

There is conflicting research that I found about whether non-suicidal self-injury is a behavioral addiction, but I've had many clients describe it that way.  I've had clients come in and say, "I've been clean from self-harm for three months," or they'll describe it as feeling like they got the urge to engage in the behavior and then got that release. Sometimes they will describe it in addictive terms. If clients use that type of language, I often connect with some type of motivational interviewing or maybe we look at a 12 step system for treating non-suicidal self-injury.

Motivational interviewing takes a look at what stage are they in.  Are they in that pre-contemplation phase where "this isn't a problem"? Are they in that contemplation phase where "yes, this is a problem"? There are specific interventions to help them get to a different stage. If you are doing substance treatment with an individual that has non-suicidal self-injury, (because it's all about coping) there may be some comorbid things happening at the same time that may be using the same treatment that you're using for the addictions may actually help support the behavior of non-suicidal self-injury as well. 

There is also an approach called harm reduction instead of harm elimination where the goal is to reduce the behavior. I work with kids and teens and my goal is always no behaviors, but if I have a client that's engaging in the behavior every day then sometimes the initial goal is to get those numbers down and see if we can reduce that behavior. Encourage when they didn't engage in behavior and ask what helped not perform that day? And the goal, to be seeing the number go down. Harm reduction comes out of that addiction space where sometimes they gave people clean instruments to inject themselves to reduce the risk of having some type of infection and so that's where you'd have to research if harm reduction was something that you thought would be helpful within your scope of practice. Because I work a lot with kids and teens, I typically use it as an overarching where, yeah, the goal's gonna be zero, but nobody's gonna be mad if you did engage in the behavior because we're gonna talk about what was the trigger? What skills did you try? If you were able to do a skill before engaging in the behavior? And then maybe resetting the clock of all right, so now we're gonna restart from here and can you agree to not engage in behavior until this next session? 

Grounding Techniques

Grounding techniques are very helpful if the individual has dissociative symptoms and they're engaging in this behavior or feeling outside of their body (that emotional numbing where they're not feeling real).

Examples of grounding techniques are:

• Using the Senses. The five things you see, four things you feel, three things you hear, two things you smell, and one thing you taste. If you are working with a very young client or cognitively limited client, you might just say three things you see, three things you hear, and three things you taste. Their emotional brain is overly stimulated and grounding techniques can help calm that emotional part of the brain where they can feel more grounded in reality, more grounded in their body. This is a great technique to use in sessions with a client who is becoming escalated but their energy really isn't. I describe it as they're way outside their body and sometimes I will say "all right, let's stop. Can you feel where you are?  Let's try a technique".  Grounding techniques can be a great option that the client can use both in session and outside of the session. 
• Butterfly technique.  Draw a butterfly on the place that they want to harm and the goal is to protect the butterfly; don't hurt the butterfly.  The butterfly technique also works with other animals, images, or the name of someone in their family they care about. I've edited that to say write the name of your favorite sister or your favorite sibling and then protect your sibling in the space where they would want to engage in the self-harm. That works better sometimes because often they really don't care about the idea of harming themselves, but the idea of harming something that they care about or harming someone else can be very helpful. You want to partner with the families, especially if you're working with kids or teens, so that they know what it's for and that they'll allow them to write on themselves.
• Apps. There's one app called Calm Harm and it's by the app Calm. They have one specifically for people who are having thoughts of self-injury. There are also lots of other apps. Kids, teens, and adults typically have their phone close to them.  If they're having those thoughts, to have a quick app that they can open can help them with managing those thoughts. 

Dialectical Behavioral Therapy Skills Training

Dialectical behavior therapy (DBT) was developed by Marsha Linehan. 

DBT skills training is where you learn about the skills training and you teach clients specific skills.  Those skills include: 

• Mindfulness Skills
• Emotion regulation skills
• Distress tolerance
• Interpersonal effectiveness skills 

There is a list of different interventions that you can use for each one of those skills.

Some people who are fully trained to do DBT, offer the individual program, group therapy, and then also crisis intervention when needed. You don't want to say that you're doing DBT if you don't have a certification. I've completed multiple trainings on DBT and I teach clients skills and incorporate that within the treatment.  I don't have the DBT certification, so I don't market myself as a DBT therapist because that is a separate certification.  However, if you have received additional training on doing the skills involved in DBT, that can be something that you incorporate into practice. I found it to be helpful, especially in working with this population.

Other Types of Treatment

There are lots of other effective treatments. Cognitive behavior therapy to help them change how they're thinking is one of them.

Applied Behavior Analysis (ABA) can work with individuals that have autism, developmental disorders, or intellectual disabilities. Helping families find something else to replace the behavior within that behavioral paradigm is key because sometimes the individual will be triggered by "no" and not getting their way.  Families will then give them their way so that they don't engage in the behavior, but that actually reinforces the behavior and so you need to figure out ways to create safety while you're trying to have the family set appropriate boundaries. 

Eye Movement Desensitization and Reprocessing (EMDR) is a treatment program that you have to get additional training in and but it's very effective based on research with helping individuals.  During this program, you're locating that pain and with that pain are the trauma flashbacks or issues that are trauma-related.  EMDR is very effective.

There are some psychotropic medications that have been found to be helpful.  You will need to refer to a psychiatrist or their medical doctor to discuss different options regarding medications. Being aware is key because sometimes some medications can increase certain thoughts.  For example, the client starts a new medication and their self-harm thoughts have increased. You need to be aware of that and have them go back to their doctor to discuss the change in thoughts with the new medication. 

Resources

There are some resources here. There are lots of great books and training manuals and so I've listed some of my favorites, once again, I'm not affiliated with any of these, I don't get anything if you do check these out.

These are just some resources that I've used in working with this population.

• 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 
• The Stop Walking on Eggshells Workbook: Practical Strategies for Living with Someone Who Has Borderline Personality Disorder (A New Harbinger Self-Help Workbook)  by Randi Kreger, James Paul Shirley LMSW
• 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 
• Nonsuicidal 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)

Summary

- [Katrinna] Thank you so much, Dr. Berry, for sharing your expertise with us. Social workers are trained in dealing with suicidal clients although social workers tend to have limited training on managing non-suicidal self-injury as clients. Therefore, it is very important that social workers recognize non-suicidal self-injury are able to identify common myths regarding self-injury and ultimately are able to appropriately assess safety plans and treat clients who present with non-suicidal self-injury. Please note that cultural competence is essential to our work as social workers. Therefore, we must be aware of the role of culture and diversity and its impact on practice. For more information regarding cultural competent practice, please review the NASW resource standards and indicators for cultural competence and social work practice. Again, thank you for joining us on Social Work at continued.com.

References

Refer to the course handout for a complete list of references.