NON-SUICIDAL SELF-INJURIOUS BEHAVIORS(NSSI)

Imelda V. G. Villar, Ph. D.

DEFINITION

Direct, deliberate, self-inflicted damaging of

tissue

Without intent to die and without social sanction

Superficial/moderate amount of tissue damage

Not associated with neurological illness, developmental disorder

(Klonsky & Glenn, 2007)

COMMON METHODS

Cutting, burning, hitting, needle pricking, hair

pulling, obstructing wound healing, severe scratching

Cutting often identified as most common method

Most employ multiple methods

(Briere & Gil, 1998; Nock et al., 2006; Ross & Heath, 2002)

FUNCTIONS OF BEHAVIOR

“After I have harmed myself, I feel a lot calmer

and relaxed, as if I’ve got the bad out.” (Harris, 2000, p. 167)

Tension reduction

Influencing social exchanges

Expression of self-punishment

(Briere & Gil, 1998; Nock et al., 2006; Ross & Heath, 2002)

CHARACTERISTICS OF PERPETRATORS

Low self-esteem and self-criticism

Felt unloved or rejected as children

Expressing anger toward others perceived as potential cause for further rejection; thus, they become intropunitive

Experience frequent and intense negative emotions – including depression, anxiety and anger (Klonsky & Muehlenkamp, 2007)

Have difficulty being aware of and expressing them(Gratz, 2006)

MALADAPTIVE NATURE

Obvious negative physical consequences

Research indicates most prefer to stop this behavior

“I really would like to stop self-harming but feel I cant because I am addicted to it. I couldn’t live without the release.” (Harris, 2000, p. 169)

PSYCHOLOGICAL AND PSYCHOSOCIAL CORRELATES:

Personality disorders (e.g. BPD, antisocial) Elevated anxiety and depression Emotional dysregulation and

inexpressivity Dissociation and posttraumatic stress Disordered eating Substance abuse Reduced self-esteem Self-critical cognitive style History of childhood emotional, physical

and/or sexual abuse

(Aizenman & Jensen, 2007; Evren & Evren, 2005; Glassman et al., 2007; Hilt et al., 2008; Paivio & McCulloch, 2004; Ross & Health, 2002; Van der Whitlock et al., 2006; Yates et al., 2008; Zlotnick et al., 1999)

EFFECTS

Does not usually cause death

Accidental slip can cause fatal results

Evident wounds/scars can create unsolicited reaction which aggravates feelings of rejection

Lead to permanent physical scars for life

SIGNS & SYMPTOMS

Unexplained scars or marks

Fresh cuts, bruises, burns, or other signs of bodily damage

Bandages or wide accessories worn frequently, inappropriate dress for the season

Unwillingness to participate in events requiring less body coverage (e.g., swimming)

Razor blades or other cutting implements

SIGNS & SYMPTOMS

Physical or emotional absence, social withdrawal, sensitivity to rejection

Difficulty handling anger

Compulsiveness

Expressions of self-depreciation, shame, and/or worthlessness (some highly functional and socially engaged individuals also self-injure)

(Whitlock, Eckenrode, et al., 2006)

TASKS OF SIGNIFICANT OTHERS

Be supportive, direct and honest about observation and concerns. • “I notice that you have wounds on your

arms. I know that this can be a sign of self-injury. Are you deliberately hurting yourself?”

Walsh’s (2006) “respectful curiosity” – asking simple questions in calm, caring ways• “Where on your body do you tend to injure

yourself?”• “Do you find yourself in certain moods

when you injure yourself?”• “Are there certain things that make you

want to injure yourself?”

RESPONDING TO DENIAL

If the individual denies self-injuring or avoids the questions, respect for privacy must be applied with a warm invitation. “I respect your desire to keep this to yourself. But if you wish to talk about anything, I am here for you.”

If there is seeming danger to life, vigilance and professional assistance are a must. Experts can offer support, guidance and advice, and help identify and understand underlying causes of NSSI.

OTHER TASKS

Help self-injurious students considered “cool” or role models to understand that when they talk about or show their self-injury to peers, risks of contagion occur.

Ensure NSSI that students cover wounds or scars when coming to school to prevent infection, undue attention, or contagion.

Extend full acceptance, unconditional love, care and respect to restore their self-esteem and self-love in very palpable and consistent ways

Help build on their strengths is an important step to recovery and non-recurrence.

ASSESSMENT

Method(s) employed and types of tools (e.g. knife)

Location of injury on body (e.g., legs, arms)

Frequency of use in past year and past month

Tissue damage: typical amount; greater damage ever incurred

(Walsh, 2007)

ASSESSMENT

Lifetime history of NSSI (e.g., age of onset, remission)

Phenomenology/conditions surrounding use• “Tell me about the last time you cut yourself…”

Perceived function (e.g., tension reduction)

Sense of control while injuring• “Some feel out of control and cut more than

expected…”

(Walsh, 2007)

ASSESSMENT

Use of drugs/alcohol during NSSI

History of medical attention and complications; need for medical referral (e.g., insertion of pins)

Current motivation for stopping behavior

Asking to see self-injuries (within bounds of modesty) for objective information

TREATMENT ISSUES

Therapeutic Relationship:

Open, nonjudgmental, understanding space

Examining own personal reactions to NSSI• Shock, anxiety, fear, disgust

(Craigen & Foster, 2009; Walsh, 2007)

TREATMENT ISSUES

Therapies with support:• Cognitive behavioral therapy• Dialectic behavioral therapy

Recommendations for combination between:• Modifying behaviors• Learning to accept unsettling emotions

(Klonsky & Muehlenkamp, 2007; Nock, Teper & Hollander, 2007)

BEHAVIORAL STRATEGIES

Triggers/Antecedents to NSSI:• Cognitive (irrational thoughts)• Affective (emotions prior to NSSI)• Behavioral (habits, rituals prior to NSSI)

Help illuminate purpose behind NSSI

(Walsh, 2007)

BEHAVIORAL STRATEGIES

Replacement Skill Training:

Affect regulation• Journaling• Mindful breathing (tolerating negative affect)

Communicating skills• Assertiveness training

Create detailed behavioral plan

(Walsh, 2006; Walsh, 2007; Wester & Trepal, 2005)

(Walsh, 2007)

COGNITIVE STRATEGIES

Research on cognitive variables:• Childhood abuse self-critical style NSSI• Social self-efficacy (Nock & Mendes, 2008)

Identifying maladaptive thought patterns

Reforming thoughts: more adaptive alternatives

NEUROLINGUISTIC PROGRAMMING

Global Anchoring – rewriting history

Global Unconscious Reframing

Personal Power Radiator

ETHICAL ISSUES

Right to privacy vs. protection from “serious and foreseeable harm” (ACA Code of Ethics, 2005)

– 20% harmed self more severely than expected at least once (Whitlock et al., 2006)

– 34% frequently fell out of control of NSSI (Briere & Gil, 1998)

If minor client, issues related to notifying parents