By Barent Walsh, Ph.D., Executive Director, The Bridge. Author; Treating Self-Injury: A Practical Guide
I have defined non-suicidal self-injury (NSSI) as “intentional, self-effected, low lethality bodily harm of a socially unacceptable nature performed to reduce and/ or communicate psychological distress” (Walsh, 2006, p 4.). Common examples of NSSI include body cutting, scratching, abrading, self-hitting, self-burning, and picking at wounds. NSSI is a particularly puzzling behavior because it goes against the normal human tendency of self-protection. Extensive research conducted since decade 2000 (e.g. Nock & Prinstein, 2004; Klonsky, 2007) has shown that the majority of individuals who self-injure do so to regulate (reduce) emotional distress and to express or confirm self-derogatory beliefs. In addition, people self-injure in order to influence the behavior of others by garnering attention, obtaining support, effecting a reconciliation, escaping, and so on. These latter interpersonal functions have been found to be of secondary importance to the internal affect regulation functions.
Self-injury should be differentiated from suicidal behavior in terms of a number of key characteristics. See Table I for some key points of difference. However, it should also be noted that when self-injury persists, it has been found to be a strong predictor of subsequent suicide attempts (but not necessarily completions) (Nock, 2010).
Of special concern is that self-injury has recently moved from clinical populations such as those served in psychiatric hospitals and group homes to the general population including middle, high school and college students. A large number of studies conducted internationally since the late 1990s have found rates of NSSI to range from 6 to 20% in youth in developed countries. Some of these youth are very high functioning in major sectors of their lives yet still self-injure at high rates. For example, Whitlock and colleagues (2006) found that 17% of a sample of over 3000 undergrads at Cornell and Princeton Universities had self-injured. Thus, it is inappropriate to assume that if someone self-injures they must suffer from severe psychopathology. Many youth are quite capable, but unfortunately manage their internal or interpersonal distress using self-injury.
Emerging evidence suggests that NSSI is especially prone to social contagion influences (Walsh, 2006; Walsh & Doerfler, 2009; Nock, 2010). Youth may influence each other face to face or increasingly on the internet via chatrooms, message boards, and YouTube (Lewis et al. 2011). More specifically, many postings on YouTube show youth actively self-injuring on camera – which can be immensely triggering for others.
The good news is that NSSI is treatable, although gold standard randomized clinical trials are wanting. Nonetheless, there is considerable evidence that skills based interventions such as cognitive therapy or dialectical behavior therapy are useful in the treatment of NSSI (Muehlenkamp, 2007; Miller, Rathus & Linehan, 2007; Walsh & Doerfler, 2009). The focus of such treatment is to teach clients skills to regulate their emotions or communicate their interpersonal needs more effectively. One thing professionals should not do is treat self-injury in groups where details of self-harm are discussed. This may serve to trigger contagion effects mentioned above.
Klonsky, D. E. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226-239.
Lewis, S.P., Heath, N.L., St. Denis, J.M. & Noble, R. (2011). The scope of nonsuicidal self-injury on YouTube. Pediatrics; originally published online February 21, 2011; DOI: 10.1542/peds.2010-2317
Miller, A.L., Rathus, J.H. & Linehan, M.M. (2007). Dialectical behavior therapy for suicidal adolescents. New York: Guilford.
Muehlenkamp, J. J. (2006). Empirically supported treatments and general therapy guidelines for non-suicidal self-injury. Journal of Mental Health Counseling, 28, 166-185.
Nock, M.K. (2010). Self-injury. Annual Review of Clinical Psychology, 6, 339-363.
Nock, M. K. & Prinstein, M. J. (2004). A functional approach to the assessment of self- mutilative behavior. Journal of Consulting and Clinical Psychology, 72(5), 885-890.
Walsh, B. (2006). Treating self-injury: A practical guide. New York: Guilford Press.
Walsh, Barent & Doerfler, Leonard A. (2009). Residential treatment of self-injury. In Nock, M. K. (Editor), Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: American Psychological Association.
Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious behaviors in a college population. Pediatrics, 117(6), 1939-1948.