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 Reinforcement||Negative Reinforcement|
|Internal||Increase emotional intensity (for dissociators)||Decrease intensity of emotions|
|External||Communicate pain; obtain help||Escape 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-harm||Cons of self-harm|
|It is easy and quick.||More scars|
|Easier to have physical pain than emotional pain||Lose the trust of my family/friends/treatment providers|
|Allows me to be numb||Increases my shame|
|Have proof of how much pain I am in||Doesn’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.
Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal self-injury: A systematic review. Front in Psychol. 8: 1946.
CBT for Personality Disorders
April 8-10, 2019