Skip to content
  • Donate Now
  • Seeking Treatment?
  • Cart
  • Account
  • Cart
  • Account
Beck Institute
  • CBT & CT-R Training
    • Training for Organizations
    • Training for Professionals
    • Center for CT-R
    • Full Training Catalog
    • Supervision
    • Consultation
    • On-Demand Training
    • Discounts, Financial Aid, and Scholarships
    • Continuing Education
  • Certification
    • Beck Institute CBT Certified Clinician (BICBT-CC)
    • Beck Institute CBT Certified Master Clinician (BICBT-CMC)
    • Beck Institute CBT Certified Supervisor (BICBT-CS)
    • Work Sample
  • CBT & CT-R Resources
    • Beck Institute Newsletter
    • CBT Insights Blog
    • Resources for Professionals and Students
    • Resources for Non-Professionals
    • International Resources
    • Emergency Response Resources
    • FAQs
  • About Us
    • History of Beck Institute
    • Understanding CBT
    • Our Team
    • Dr. Aaron T. Beck
    • Dr. Judith S. Beck
    • Employment Opportunities
    • The Beck Institute Clinic
    • Press Room
  • Therapy & Coaching Services
    • Beck Institute Clinic
    • Beck Institute Weight Management
  • My Account
    • My Certification
    • My Training
  • CBT & CT-R Training
    • Training for Organizations
    • Training for Professionals
    • Center for CT-R
    • Full Training Catalog
    • Supervision
    • Consultation
    • On-Demand Training
    • Discounts, Financial Aid, and Scholarships
    • Continuing Education
    • Donate Now Seeking Treatment?
    • fab fa-facebook fab fa-linkedin-in fab fa-x-twitter fab fa-youtube
  • Certification
    • Beck Institute CBT Certified Clinician (BICBT-CC)
    • Beck Institute CBT Certified Master Clinician (BICBT-CMC)
    • Beck Institute CBT Certified Supervisor (BICBT-CS)
    • Work Sample
    • Donate Now Seeking Treatment?
    • fab fa-facebook fab fa-linkedin-in fab fa-x-twitter fab fa-youtube
  • CBT & CT-R Resources
    • Beck Institute Newsletter
    • CBT Insights Blog
    • Resources for Professionals and Students
    • Resources for Non-Professionals
    • International Resources
    • Emergency Response Resources
    • FAQs
    • Donate Now Seeking Treatment?
    • fab fa-facebook fab fa-linkedin-in fab fa-x-twitter fab fa-youtube
  • About Us
    • History of Beck Institute
    • Understanding CBT
    • Our Team
    • Dr. Aaron T. Beck
    • Dr. Judith S. Beck
    • Employment Opportunities
    • The Beck Institute Clinic
    • Press Room
    • Donate Now Seeking Treatment?
    • fab fa-facebook fab fa-linkedin-in fab fa-x-twitter fab fa-youtube
  • Therapy & Coaching Services
    • Beck Institute Clinic
    • Beck Institute Weight Management
    • Donate Now Seeking Treatment?
    • fab fa-facebook fab fa-linkedin-in fab fa-x-twitter fab fa-youtube
  • My Account
    • My Certification
    • My Training
    • Donate Now Seeking Treatment?
    • fab fa-facebook fab fa-linkedin-in fab fa-x-twitter fab fa-youtube
  • Donate Now Seeking Treatment?
  • fab fa-facebook fab fa-linkedin-in fab fa-x-twitter fab fa-youtube
Home CBT Insights Non-Suicidal Self-Harm: Conceptualization and a Clinical Intervention
  • All Conditions

Non-Suicidal Self-Harm: Conceptualization and a Clinical Intervention

February 21, 2019 / by Beck Institute Staff
Categories: All Conditions Personality Disorders Success Stories

Browse by Topic


  • Everything
  • Aaron T. Beck
  • ADHD
  • All Conditions
  • Anger
  • Anorexia
  • Anxiety and Panic Disorders
  • Beck Announcements
  • Beck in the News
  • Bipolar Disorder
  • Bulimia
  • CBT Certification
  • CBT Training
  • Chronic Fatigue Syndrome
  • Chronic Pain
  • CT-R
  • Depression
  • Digestive Issues
  • Emotional Disorders
  • Fibromyalgia
  • Impact of CBT
  • Insomnia
  • Judith S. Beck
  • Migraines
  • Newsroom
  • Obsessive Compulsive Disorder
  • Other
  • Panic Disorder
  • Personality Disorders
  • Practitioner Tips
  • PTSD
  • Relationship Problems
  • Schizophrenia
  • Sexual Dysfunctions
  • Social Phobia
  • Substance Use Disorders
  • Success Stories
  • Suicide
  • Training for Organizations
  • Weight Management

Non-Suicidal Self-Harm: Conceptualization and a Clinical Intervention

By Amy Cunningham, PsyD
Beck Institute Faculty

Non-suicidal self-injury (NSSI) is defined as an act of intentional self-inflicted bodily harm without suicidal intent, for purposes that are not socially-sanctioned. NSSI has been linked to numerous psychiatric disorders, including borderline personality disorder, post-traumatic stress disorder, and eating disorders.

The prevalence rates of NSSI have risen steadily, causing clinical and public health concerns. Recent research estimates prevalence rates as follows: 7.5% to 46.5% in adolescents; 38% in university students; and 4% to 23% in adults (Cirpriano et al, 2017).

This behavior can be alarming not only to individuals’ friends and family members, but also to their therapists. Many therapists struggle to understand how and why clients might be driven to harm themselves in times of distress. Fear, lack of case conceptualization and lack of knowledge of effective therapeutic interventions often lead to stigma and a decreased desire to work with clients who engage in NSSI. Gaining an understanding of how to effectively work with clients who engage in NSSI is critical.

Understanding the Experience

Most people who engage in NSSI experience intense shame related to self-harm. Most have had the experience of being harshly judged for their behavior. As a result, they fear that they’ll be rejected if they disclose their NSSI. Additionally, they may fear that others will assume they are suicidal and refer them to the hospital. Finally, some individuals are fearful of being labeled “manipulative” or being told they “just want attention” if they disclose their NSSI.

Given this intense shame and fear, it is important for therapists to feel comfortable discussing NSSI directly and without judgment. A helpful homework assignment for therapists is to stand in front of a mirror and say the words “self-harm,” “cut yourself,” and “self-injury” over and over again until they can say them without hesitation, or emotional reaction. If therapists find this exercise difficult, or become aware of their own distorted thinking about NSSI, they can practice cognitive modification on themselves!

Most people who engage in NSSI do want help to stop this behavior. However, as a result of their shame and fear, they are not likely to put it on the agenda or list it as a therapy goal. Thus, it is important for therapists to validate the individual’s emotional experience regarding NSSI. Therapists can validate their clients’ emotions without validating their behavior. For example, it would be helpful to say, “It must be hard for you to feel that the only way to get someone to listen is to cut yourself.” Or therapists might say, “I can understand how sad you must feel, to believe the only way to stop your pain is to cut yourself.” This validation will go a long way toward building a strong therapeutic relationship.

Understanding the function of the NSSI is critical to developing an effective intervention. This behavior, much like other maladaptive and addictive coping strategies, provides both internal and external, and positive and negative reinforcement. Internally, NSSI can either increase one’s emotional or physiological experience, (i.e. if the individual is dissociating) or it can decrease the intensity of one’s internal experience, (i.e. if the individual is experiencing intense emotions that they believe are intolerable). Externally, NSSI can function to communicate pain with the intent of obtaining help. It may also serve to help the individual escape responsibilities or demands put on them by others.

This chart outlines the functions NSSI can serve:

Positive ReinforcementNegative Reinforcement
InternalIncrease emotional intensity (for dissociators)Decrease intensity of emotions
ExternalCommunicate pain; obtain helpEscape responsibilities or demands

The same behavior can serve several different functions for the same client. It is critically important to conduct a thorough assessment each time a client engages in NSSI. During the assessment, key factors to consider include the client’s thoughts, feelings and behaviors that occurred before the episode of NSSI. An ideal place to start is the point when the client first had urges or thoughts about NSSI.

It is also important to review the events that occurred after the episode of NSSI. This will enable the therapist to examine if there are any behaviors that are inadvertently reinforcing the NSSI. For example, if the clients’ family or friends express love and concern after an episode of NSSI, clients may learn that by engaging in NSSI they receive caring. This reinforcement makes it more likely that the client will engage in NSSI in the future and may decrease their willingness to stop the behavior. After a careful assessment of the events (both internal and external) that preceded the episode of NSSI, and the consequences of the behavior, the therapist will be in a much better position to help the client find alternative ways to cope with their experience.

A Clinical Intervention

After a thorough assessment of the NSSI has been conducted, a helpful initial intervention is to create a pros and cons list of NSSI with the client in session. It’s important to openly acknowledge the clear benefits of NSSI; if there weren’t, the client would no longer be engaging in the behavior. Most clients, due to shame, are reluctant to admit the advantages. However, therapists can validate clients by saying something like, “I believe you’re getting benefits from cutting and it’s my job to help you figure out how you can get those same benefits without cutting and all of its disadvantages.”

An example of a pros and cons list for self-harm is below:

Pros of self-harmCons of self-harm
It is easy and quick.More scars
Easier to have physical pain than emotional painLose the trust of my family/friends/treatment providers
Allows me to be numbIncreases my shame
Have proof of how much pain I am inDoesn’t actually fix the problem that lead to feeling badly in the first place
Communicates that my pain is real

By discussing the pros and cons of NSSI, therapists validate their clients’ feelings and also gain a better understanding of what makes it hard for each particular client to change his or her behavior. In addition, conversations about the pros and cons of NSSI lay out a road map of potential treatment goals. Future sessions could focus on helping the client achieve the benefits of NSSI in ways that are not self-destructive. For example, interpersonal skills training can help clients learn to effectively communicate their pain to others, without engaging in NSSI. Finally, a between-session assignment could be for clients to look at this list every day, or make this list into a coping card (on an actual or virtual card) and keep it in an easily accessible place, so they can review it when urges for NSSI arise.

References

Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal self-injury: A systematic review. Front in Psychol. 8: 1946.


Upcoming Workshop

CBT for Personality Disorders

April 8-10, 2019

Learn More
PREVIOUS ARTICLE
Clinical Measures in CBT – A Hassle or a Help?
NEXT ARTICLE
What is Recovery-Oriented Cognitive Therapy (CT-R)?
Sign Up for
Our Newsletter

View a sample newsletter



Beck Institute for Cognitive Behavior Therapy
One Belmont Avenue, Suite 503 Bala Cynwyd, PA 19004-1610 +1 (610) 664-3020 help@beckinstitute.org Contact Us
© 2025 Beck Institute for Cognitive Behavior Therapy
  • Privacy Policy
  • Terms of Use
  • Refund and Cancellation Policy
  • Permission to Use Beck Institute Materials
  • Sitemap
  • fab fa-facebook
  • fab fa-linkedin-in
  • fab fa-x-twitter
  • fab fa-youtube
Beck Institute Cares