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