March is Self-Harm Awareness Month, so we thought we’d share what we know about this important topic.
What exactly is self-harm?
Non-Suicidal Self-Injury (NSSI) is defined as any deliberate act of harm to one’s body without suicidal intent (Nock, 2009). It can include behaviors like burning or picking at wounds, but hitting oneself on purpose and cutting with sharp objects have been found to be the most common methods of NSSI (Muehlenkamp & Gutierrez, 2007).
Some youth engage only in NSSI with no suicidal behaviors (Jacobsen, Muehlenkamp, Miller, & Turner, 2008). However, that does not mean that NSSI is any less serious. The only thing that differentiates NSSI from suicidal behavior is intent to die, and intent can quickly change leading up to and/or during the act. Even without intent, NSSI can still be fatal (Miller & Smith, 2008). Most importantly, NSSI is a significant precursor to suicide (Hankin & Abela, 2011), which is currently the second leading cause of death in this country among youth and young adults between the ages of 10-24 years (CDC, 2018). Some studies have shown that NSSI is an even stronger predictor of suicide attempts than a prior history of attempts itself (Ribiero et al., 2016).
NSSI is not an attempt to “manipulate” others, and it is not inherently “attention-seeking.” Conceptualizing it as such may cause adults to minimize, dismiss, or intentionally ignore NSSI as an attempt to extinguish the behaviors. It may misguide adults into thinking that if they do not attend to it, the behaviors will eventually go away. However, this can be an extremely harmful response to known NSSI. Youth may feel invalidated or uncared for, resulting in escalation of behaviors and greater emotion dysregulation. There are many possible reasons why youth may engage in NSSI, including escape or relief from psychological pain, to feel something if emotional numbing is present (e.g., after experiencing trauma), to obtain care and concern if they lack the skills to ask for help effectively, etc. It is important to start with validation, and provide appropriate help and support to address the underlying factors.
When and how often does it happen?
Lifetime estimates of NSSI is 17.2% among adolescents (Swannel, Martin, Page, Hasking, & John, 2014), with approximately 2.1 million adolescents estimated to engage in NSSI each year (Muehlenkamp & Gutierrez, 2007). Youth typically first engage in NSSI between the ages of 12-14 years (Nock & Prinstein, 2004).
Who is most at risk?
It’s unclear whether it happens more often among females than males, as the literature is mixed (Muehlenkamp & Gutierrez, 2004). Some studies find no gender differences, whereas others find that it occurs more commonly among girls than boys.
What we do know is that NSSI is significantly more common among sexual minority adolescents compared to heterosexual adolescents, with LGBQ adolescents being 3-6 times more likely to engage in NSSI (Liu et al., 2019).
Higher rates of Major Depressive Disorder (MDD), externalizing disorders like Attention-Deficit/Hyperactivity Disorder (ADHD) or Oppositional Defiant Disorder (ODD), substance use, and borderline personality features are also found among those who have engaged in NSSI compared to those who haven’t (Jacobsen et al., 2008; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006).
What can you do if your child engages in NSSI?
Get comfortable being uncomfortable, and address it directly with your child! For example, “I noticed that there were some cuts on your arm that looked like you might have done it to yourself on purpose. Can you tell me more about that?” It can be an uncomfortable and difficult conversation to have, and it’s important to model open and honest conversations about risk. This can serve to reinforce the message that all feelings are acceptable, and mental health issues are not taboo topics in your home. Your child may also be more likely to come to you for help and support the next time they are experiencing NSSI thoughts or urges, before engaging in NSSI behaviors.
Seek professional help from a mental health provider. If your child is already connected to care, make sure to notify their therapist immediately to ensure it gets addressed in the next session. This is especially important, if your child has never engaged in NSSI before and/or you are noticing an escalation in behaviors. It is also worth discussing whether the current therapy is adequate for addressing NSSI or if a higher level of care is needed.
Look into specialized treatments for NSSI and suicidal behaviors in youth, such as Dialectical Behavior Therapy for Adolescents (DBT-A; Rathus & Miller, 2002). Comprehensive DBT-A consists of four modes of treatment with adolescents and their caregivers: 1) weekly individual therapy, 2) weekly multi-family DBT skills training group, 3) phone consultation, and 4) therapist consultation team. DBT-A is a well-established treatment for decreasing the frequency of NSSI and suicide attempts in adolescents. DBT-A has repeatedly been found to be significantly more effective at reducing NSSI and suicide attempts in adolescents in both outpatient and inpatient settings compared to treatment as usual or even enhanced usual care (McCauley, Berk, & Asarnow, 2018; McMain, Links, & Gnam, 2009; Tebbett-Mock, Saito, McGee, Wolozyn, & Venuto, 2020). While comprehensive DBT-A is not always be needed, it may be indicated for youth engaging in NSSI with multiple mental health diagnoses and problems.
To find a DBT-certified clinician in your area, search the directory: https://behavioraltech.org/resources/find-a-therapist-app/wpbdm-region/united-states/
University-based graduate training clinics are also excellent resources for finding low cost DBT services in your area, such as the Dialectical Behavior Therapy Clinic at the Joan and Arnold Saltzman Community Services Center at Hofstra University in New York (https://www.hofstra.edu/saltzman-center/counseling-mental-health-clinic.html) or the Dialectical Behavior Therapy Clinic at Rutgers University in New Jersey (https://gsapp.rutgers.edu/centers-clinical-services/DBT/services)
Consider utilizing suicide hotlines, such as:
- National Suicide Prevention Lifeline (800-273-8255)
- Crisis Text Line (text “talk” to 741-741)
- NYC WELL (Call 888-NYC-WELL, text “Well” to 65173)
- NJ Hopeline (855-654-6735)
- TrevorLifeline for LGBTQ youth in crisis (866-488-7386)
Centers for Disease Control and Prevention (CDC). Ten leading causes of death and injury. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at: https://www.cdc.gov/injury/wisqars/leadingcauses.html. Published April 13, 2018. Accessed May 23, 2018.
Hankin, B. L., & Abela, J. R. (2011). Nonsuicidal self-injury in adolescence: Prospective rates and risk factors in a 2 ½ year longitudinal study. Psychiatry Research, 186, 65–70. https://doi. org/10.1016/j.psychres.2010.07.056
Jacobson, C. M., Muehlenkamp, J. J., Miller, A. L., & Turner, J. B. (2008). Psychiatric impairment among adolescents engaging in different types of deliberate selfharm. Journal of Clinical Child and Adolescent Psychology, 37.
Liu, R. T., Sheehan, A. E., Walsh, R. F., Sanzari, C. M., Cheek, S. M., & Hernandez, E. M. (2019). Prevalence and correlates of non-suicidal self-injury among lesbian, gay, bisexual, and transgender individuals: A systematic review and metaanalysis. Clinical Psychology Review, 74, 101783. https://doi. org/10.1016/j.cpr.2019.101783
McCauley, E., Berk, M.S., Asarnow, J.R., Adrian, M., Cohen, J., Korslund, K., Avina, Cl., Hughes, J., Harned, M., Gallop, R., & Linehan, M. (2018). Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized controlled trial. JAMA Psychiatry. 75(8), 777-785
Mehlum, L., Tørmoen, A.J., Ramberg, M., Haga, E., Diep, L.M., Laberg, S., Larsson, B.S., Staley, B.G., Miller, A.L., Sund, A.M., & Groholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: A randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53(10), 1082-1091.
Miller, A.L. & Smith, H.L. (2008). Adolescent non-suicidal self-injurious behavior: The latest epidemic to assess and treat. Applied and Preventive Psychology, 12, 178-188.
Muehlenkamp, J. J., & Gutierrez, P. M. (2004). An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide and Life Threatening Behavior, 34, 12–23.
Muehlenkamp, J. J., & Gutierrez, P. M. (2007). Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Archives of Suicide Research, 11, 69–82
Nock, M., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 65–72.
Nock, M. K. (2009). Why do people hurt themselves? New insights into the nature and functions of self-injury. Current Directions in Psychological Science, 18(2), 78–83. https://doi. org/10.1111/j.1467-8721.2009.01613.x
Rathus, J.H., & Miller, A.L. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life-Threatening Behavior, 32(2), 146-157.
Ribeiro, J. D., Franklin, J. C., Fox, K. R., Bentley, K. H., Kleiman, E. M., Chang, B. P., & Nock, M. K. (2016). Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: A meta-analysis of longitudinal studies. Psychological Medicine, 46(2), 225–236. https://doi.org/10.1017/ S0033291715001804
Swannell, S.V., Martin, G.E., Page, A., Hasking, P., & John, N.J.S. (2014). Prevalence of nonsuicidal selfinjury in nonclinical samples: systemic review, meta-analysis and meta-regression. Suicide and Life-Threatening Behavior, 44 (3), 273-303.
Tebbett-Mock, A.A., Saito, E., McGee, M., Woloszyn, P., & Venuti, M. (2020). Efficacy of Dialectical Behavior Therapy Versus Treatment as Usual for Acute-Care Inpatient Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 59 (10), 149-156.