NON-SUICIDAL SELF-INJURIOUS BEHAVIORS (NSSI) Imelda V. G. Villar, Ph. D.

1. NON-SUICIDAL SELF-INJURIOUS BEHAVIORS(NSSI)Imelda V. G. Villar, Ph. D.

2. 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)

3. 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)

4. 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)

5. 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)

6. 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)

7. 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)

8. 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

9. 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

10. 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)

11. 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?”

12. 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.

13. 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.

14. 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)

15. 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)

16. 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

17. TREATMENT ISSUES Therapeutic Relationship: • Open, nonjudgmental, understanding space • Examining own personal reactions to NSSI • Shock, anxiety, fear, disgust (Craigen & Foster, 2009; Walsh, 2007)

18. 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)

19. 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)

20. 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)

21. 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

22. NEUROLINGUISTIC PROGRAMMING • Global Anchoring – rewriting history • Global Unconscious Reframing • Personal Power Radiator

23. 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