The challenges that students face today can be complicated and overwhelming, causing some youth to resort to self-injury to cope with the stress. According to a study by Martin Monto, Nick McRee and Frank Deryck (published as “Nonsuicidal self-injury among a representative sample of US adolescents, 2015” in the American Journal of Public Health), 1 in 4 girls and 1 in 10 boys will self-harm.

From my experience as a school counselor, I have found that the presence of self-injury often indicates significant underlying emotional issues. Given these realities, I believe it is more important than ever for counselors to familiarize themselves with this dilemma. This overview is intended to walk through what self-injury is and isn’t, who tends to be affected and how to intervene.

What is self-injury?

Self-injury, also known as nonsuicidal self-injury (NSSI), can be defined as deliberate, self-inflicted harm to body tissue without suicidal intent. This does not include behaviors that are socially accepted, such as piercings or tattoos. This definition is based on E. David Klonsky’s research presented in “The functions of deliberate self-injury: A review of the evidence,” published in Clinical Psychology Review in 2007.

NSSI includes, but is not limited to, cutting, burning, biting or scratching the skin, head banging, punching and pinching. Common injury sites include the hands, wrists, stomach and thighs, although injuries can occur anywhere on the body.

Who self-injures?

According to data taken from Jennifer Muehlenkamp and colleagues’ 2012 study, “International prevalence of adolescent non-suicidal self-injury and deliberate self-harm,” published in the journal Child and Adolescent Psychiatry and Mental Health:

• 1.3% of children ages 5-10 self-injure
• 17% of adolescents self-injure (this figure is high because it includes those who have self-injured only once)
• 5% of adults self-injure

Overall, females have been reported to self-injure more than males. They tend to prefer cutting more than any other means of self-injury, according to Janis Whitlock and colleagues’ 2011 study, “Nonsuicidal self-injury in a college population: General trends and sex differences,” published in the Journal of American College Health.

Although males are reported to self-injure less often, it is possible that this is being underreported or that the self-injury is hidden behind behaviors deemed as “more masculine.” For instance, males are more likely to deliberately bruise or cause abrasions to themselves by punching walls or instigating fights to have others hurt them.

This aligns with the incorrect perception that males have to demonstrate a certain caliber of “manliness” and that the only acceptable emotion for them to feel is anger. I have had male students who said they would be ridiculed as sissies if they expressed feeling sadness or pain or demonstrated other aspects of vulnerability. Males tend to get more “cool points” for behaviors such as picking fights or punching walls than for engaging in other types of self-harm such as cutting.

Whitlock et al. also discussed how LGBTQIA individuals are affected by self-injury. Those who identify as LGBTQIA self-injure more frequently than do their heterosexual counterparts. In particular, bisexual females were 6.2 times more likely to have engaged in self-injury at some point during their lifetime. These data showed that this subgroup is at the highest risk for NSSI out of the other populations studied in terms of gender and different types of sexual orientation. This is clearly a population at high risk that needs to be monitored.

I have found that individuals in this subgroup often self-injure because they feel split between what is expected of them and who they really are. They tend to carry a significant amount of self-blame for not meeting those expectations or feel frustrated for having what they believe to be disturbing thoughts. When their secret lives become consuming, they often turn to self-injury for “escape.”

Trauma and bullying victims are also at high risk for self-injury according to Laurence Claes and colleagues’ 2015 study, “Bullying and victimization, depressive mood, and non-suicidal self-injury in adolescents: The moderating role of parental support,” published in the Journal of Child and Family Studies. Those who have experienced trauma can internalize the event, which causes emotions that are difficult to handle and makes them more susceptible to NSSI. Clients who frequently experience bullying or peer rejection also tend to self-injure more than their counterparts do. My past students who were victims of bullying or abuse often felt that they could not fight back; in other words, they did not externalize their behavior as a coping mechanism. This then led them to an internalizing coping mechanism, which resulted in self-injury.

Myths about self-injury

The following myths are inspired by a fact sheet on top misconceptions about self-injury produced by Saskya Caicedo and Janis Whitlock for the Cornell Research Program on Self-Injury and Recovery.

Self-injury is a suicide attempt or a failed suicide attempt. Research has shown that most people who self-injure do not have the intention to die by suicide. The main motivation for self-harm is to deal with emotional stress or pain. The category name of nonsuicidal self-injury in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders provides a sense of separation from suicidal intent. This category is also being used by other organizations and in research, thus creating a distinct line between self-injury and suicidal intent. The majority of my students who self-injure have expressed no interest in ending their lives; they were simply causing superficial injuries.

Self-injury is done to seek attention. Some individuals may use self-injury as a tool to seek attention, but it is important to realize that this action still represents a desperate cry for help. Why are they going to such drastic lengths to get attention? This is a question that we, as counselors, need to ask ourselves so that we can intervene accordingly. However, the majority of those who self-injure go to great effort to hide any evidence of cuts or scars. They tend to be secretive and have a difficult time discussing the underlying issues that plague them. Those who cut in secret demonstrate extreme emotional distress and need substantial help.

Anyone who self-injures is part of the Goth or emo subgroups. Research shows that self-injury is not limited to one specific group. Self-injury does not occur on the basis of gender, socioeconomic status, sexual orientation, social group, race, profession or other categories. It is true that some groups are more affected than others by self-injury (as seen in previous demographics), but no group is completely excluded.

Someone who self-injures can quit if they really want to stop. Many experts in this area indicate that self-injury has the qualities of an addiction. The act of self-injury causes endorphins and other neurochemicals to be released in the brain, which essentially gives the person a type of “high.” The chemicals eventually dissipate, and then a craving develops to experience that feeling again. This creates a cycle of addiction that makes it even harder to stop the behavior. Many individuals may need help and additional support to be able to stop self-injuring.

Although I have students who experiment with cutting and do it out of curiosity, there is a subgroup of students who chronically self-injure. They can’t seem to “kick the habit,” no matter how hard they try. Typically, this means that their underlying issues have yet to be resolved and that an adequate replacement coping mechanism needs to be put in place.

Someone who self-injures is a danger to others. Typically, those who self-injure are people who tend to internalize their emotional issues rather than externalize them. In other words, people who self-injure take their frustrations out on themselves rather than on others. This particular trait makes it highly unlikely that people who self-injure would harm someone other than themselves.

Why do people self-injure?

From my experience, there are a few main reasons that someone may self-injure. These do not, by any means, cover every possibility. In addition, some people may have multiple reasons that motivate their behavior to self-injure.

As a coping mechanism: Based on research findings, self-injury is a way to cope with emotional pain and distress that can stem from mental illness or trauma. These two issues typically involve internalizing behaviors, which is one of the factors in the personalities of those who self-injure. Those who self-injure lack healthy coping skills that allow them to function.

To feel or to numb: Especially in cases of depression, there can be physical symptoms such as numbness and emptiness. This disconnect with the body can cause individuals to self-injure for the sake of being able to feel something again.

On the opposite end of the spectrum, some people feel too much. This tends to occur in people who may have anxiety and are overwhelmed by emotions. Self-injury for these individuals is a form of distraction that places their focus on the injury rather than on the tidal wave of emotions engulfing them.

To self-punish: People who use self-injury for this reason tend to loathe themselves and to have extremely poor self-esteem. They often are perfectionists and will punish themselves for perceived academic, athletic or social failures. This is often where the high achievers are grouped: They expect nothing less than perfection from themselves, and they “pay for it” when they believe that they have fallen short.

Immediate interventions

The following are examples of immediate interventions that counselors can take with clients who engage in self-injury.

Screen for suicide. Although it has been established that the majority of self-injury cases do not involve suicidal intent, it is important in new cases to establish which category the action falls under: NSSI or preemptive attempt of suicide.

It is always a good idea to ask some screener questions such as “Have you thought about suicide?” and “Do you have a plan?” But avoid asking, “Do you think about hurting yourself?” It is obvious that the person is already hurting themselves, and if they answer that question affirmatively, then it is likely because they are engaging in NSSI versus trying to kill themselves. However, a misunderstanding about their answer could lead to a false positive of the person being suicidal. If the person does present as suicidal, then follow additional threat assessment guidelines.

Be aware of the need for medical attention. If the individual presents with fresh injuries, counselors should be alert to possible infections, the need for stitches or other medical issues that may arise. Often, people who self-injure cover up their cuts or injuries, and the trapped moisture can cause a bacterial yeast infection. With those who have created bruising, it is important to check for possible broken bones. This evaluation also creates an opportunity for counselors to explain the risk factors that accompany self-injury and how students or clients can protect themselves from medical crises.

Notify a family member or person of support. In these situations, it is necessary to inform the individual’s parent, spouse or person of support. Self-harm is a sign of serious emotional distress, and the family needs to be made aware of what is happening so that they can be on the alert. It is also wise to talk with the person about removing any objects they could use to harm themselves, such as knives, scissors, push pins, lighters and so on. When first speaking with the student or client, try to collect information about which instruments they favor in inflicting self-harm so that there is a better idea of what objects need to be removed. Working with significant people in the client’s life is key to ensuring the client’s safety.

Supportive interventions

The following are examples of supportive interventions that counselors can use with clients who engage in self-injury.

Identify triggers. One of the best strategies for helping students or clients who engage in NSSI is to identify their triggers. Does it involve perceived failure? Does it involve feeling awkward? Does it involve rejection by peers? Once the triggers are named, the next step is to work with the student or client to outline a plan for when these triggers arise. What alternative strategy can they use? What kind of self-talk will they employ? Do they need a break from the stressful activity? All of this needs to be planned and practiced.

Identify a network of trusted individuals. What I have learned on the basis of my students’ experiences is that part of the method of operation for those who self-injure is to isolate. When students or clients do try to stop engaging in self-injury, they will need some sort of outlet for dealing with all of their complex emotions. Working with these students or clients to come up with a group of people they can trust is crucial to their recovery.

Find appropriate replacement behaviors. Odds are, the person has been using self-injury as a coping mechanism for a long time, and in order to recover, they will need to learn healthy coping strategies. Many people who struggle with self-injury are often high-sensory seeking, particularly with tactile sensory input. Replacing self-injury with fidget items that provide tactile feedback (cotton balls, string, erasers, textured stress balls, etc.) may offer more successful replacement behaviors.

Other methods of expression, such as drawing or writing, can also be beneficial because they provide an outlet for the person’s anxieties. This makes it less likely that the person will bottle up their emotions as much.

Use cognitive behavioral techniques. Cognitive behavioral techniques include identifying cognitive distortions (“thinking errors” or “thinking traps”) and learning how to engage in positive self-talk. They involve the realization that when we are thinking negatively or getting stuck on an inaccurate idea, that may skew our perspective. Some examples include:

• Mind reading: Thinking that we know what others are thinking about us
• Ignoring the good: Paying more attention to things that are bad
• Setting the bar too high: Expecting ourselves to be perfect
• Blowing things up: Making a small thing into a big deal

Once the student or client gains awareness of their faulty thinking, they can replace it with positive self-talk. For example, for ignoring the good, a student might say, “In my paper, I had trouble with this section, but I did a good job with explaining my argument overall.” For further information, refer to the “Thinking Errors” worksheet at therapistaid.com.

Encourage self-compassion. Strategies that involve identifying clients’ strengths and talents can help them to better understand and embrace their positive aspects. Helping students find activities in which they can really shine and develop their strengths is especially beneficial.

Safe websites that offer support

It is important to be wary of online supports for individuals who engage in NSSI. I have often encountered so-called support groups online whose members showed graphic pictures of self-injury in a sense of one-upmanship. These sites are triggering and tend to encourage further self-injury.

Over the years, I have found the following sites to be both helpful and safe:

• RecoverYourLife.com
• S.A.F.E. Alternatives recommended sites (selfinjury.com/referrals/sites)
• Crisis Text Line resources on self-harm (crisistextline.org/selfharm)

By using these strategies and resources, we can support our clients in developing new and positive coping skills. Together with their families and outside providers, we can make a difference in addressing NSSI.

 

 

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Lauren Appel is a behavior specialist in a North Carolina school system with a background as a school counselor. Contact her at lauren.appel@caswell.k12.nc.us.

 

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