Understanding Nonsuicidal Self-Injury Throughout the Lifespan

Nonsuicidal self-injury (NSSI) is generally defined by the American Psychological Association as the deliberate, self-inflicted destruction of body tissue resulting in immediate damage, without suicidal intent and for purposes not culturally sanctioned. The Cornell Research Program on Self-Injury and Recovery (CRPSIR) estimates that worldwide, approximately 17.2% of adolescents, 13.4% of young adults, and 5.5% of adults have engaged in NSSI, which may include cutting or scratching skin, burning oneself, hitting objects with the intention of self-harm, embedding objects under the skin, and other methods of injury.

Amanda C. La Guardia, PhD, NCC, LPCC-S, an Associate Professor of Counseling and the Counseling Program Coordinator at the University of Cincinnati, co-authored the book Non-Suicidal Self-Injury Throughout the Lifespan: A Clinical Guide to Treatment.

When assessing NSSI, Dr. La Guardia prefers to use the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) or the Deliberate Self-Harm Inventory (DSHI). “Basically, I need to know the type of self-injury being used, how long it has been going on, what tends to trigger it, and how often the person is engaging in this behavior,” she says.

Individuals engage in self-harming behavior for a variety of reasons.

“There are multiple reasons for someone to engage in NSSI,” Dr. La Guardia says. “Most of the time, clients I see are engaging in NSSI for intrapersonal reasons—to manage difficult emotions or to just feel something. However, NSSI can also serve other functions, such as a maladaptive way to manage relationships or get attention. For adolescents, there can be a social component related to a desire for belonging. If a friend is engaging in NSSI, a person might be more likely to do it themselves to stay connected with a friend. They might also do it to keep people away from them.”

NSSI is more common among adolescents, and older individuals who engage in self-injury may present differently in session, she says.

“I have seen older clients engage in NSSI to attempt to manage relationships, but what I see more of, in adulthood, is the use of NSSI to manage difficult emotions, including suicidal ideation.”

It’s important to distinguish self-injurious behavior from suicidal ideation, though they may share some similarities, she says. 

“Both involve self-directed violence; however, the purpose is different. When someone engages in NSSI, they believe they will survive. When someone makes a suicide attempt, they are hoping for death. When someone has suicidal ideation and is engaging in NSSI, they may be using self-injury to manage their suicidal impulses so they do not make an attempt. However, it is possible that the more they do this, the more they are building an acquired capability to make an attempt in the future (they stop fearing injury or pain).” Counselors must remain aware of the complexity of NSSI and thoroughly consider the context, risk factors, and information shared by each client.

Counseling clients who engage in self-injurious behavior often presents complexities that can be difficult to navigate, Dr. La Guardia says.

“Often, clients have fear that nothing else will work. While learning other less maladaptive coping strategies do work to help them manage their feelings, they take time, and they won’t get the immediate effect NSSI gives.”

Most individuals who self-injure do not attempt suicide; however, there are some indicators that a client may be at greater risk of moving from self-injury to suicidal ideation, Dr. La Guardia says.

“Trauma history, substance use, high frequency of NSSI (more than five times in a year), and depression all play a role in increased risk for suicide,” she continues. “Research shows us that adolescents engaging in NSSI are at a higher risk for suicide when compared to peers not engaging in NSSI.” Dr. La Guardia noted that the risk of shifting to a suicide attempt reduces if the person is receiving and engaging in treatment and has family support.

It is critical for counselors to provide a safe space when working with clients who self-injure, she says.

“Counselors need to focus on understanding what is going on for the individual and creating a safety plan if suicidal ideation is present. Suicidal ideation doesn’t always come along with NSSI. The goal is for clients to reduce NSSI as a coping strategy as they develop healthier skills in counseling. A strong therapeutic alliance is essential for clients to feel safe in sharing information about this behavior, especially for children. Parent education is VERY important to prevent shaming of the child at home.”
Counselors are poised to help parents or other loved ones better understand that the intention of self-injurious behavior is not death, and to address their concerns and fears.

“I reassure them that the intent is not to die, that their child is attempting to cope, and that we can work as a team to encourage the development of new, healthy coping strategies,” Dr. La Guardia says. “Like any habit, it will take time to change. I let them know if I suspect their child is thinking about suicide or has intent to kill themselves, I will involve them in safety planning. There is a lot of fear parents come with, sometimes a lot of anger, due to assumptions and misunderstandings.

“For any child under 13, when appropriate, I recommend parent–child sessions at least once every month to help foster a sense of emotional safety for the child outside of session and encourage the parent to reinforce new coping skill development outside of session,” she continues. “For adolescents, I encourage the client to bring a caregiver to session at least once every 3 months to help build support at home. I require a caregiver to be present for an initial session so I can assess parental attitudes and provide parent education as needed.”

She advises counselors who are interested in working with this population to seek specific training; look for changes in each client’s behavior; and facilitate open, nonjudgemental conversations. She recommends CAMS training and dialectical behavior therapy (DBT).

“I think aspects of habit reversal therapy can be helpful as well, especially with younger clients,” she adds. “Also, many clients engaging in NSSI have trauma histories, so familiarity with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) techniques can be helpful to treatment as well.

“Do not assume the person engaging in NSSI is suicidal or will become suicidal, but assess for it periodically, especially if something about the behavior changes (e.g., increased frequency, increased visibility, or a shift in other symptoms related to common warning signs of suicide). While there is no standardized treatment for NSSI, in my experience, externalization and naming of the behavior can be extremely helpful in creating an atmosphere where the client feels heard, where the client feels less shame, and is more open to talking about NSSI in a way that facilitates change. I frequently use DBT to help clients build mindfulness skills, assertive communication skills, and coping strategies to manage overwhelming emotions.

“Never, ever give ultimatums (e.g., if you don’t stop, I can’t work with you) or create no-harm contracts for this behavior,” she continues. “You want them to be open about what is going on, and those strategies will most certainly shut your client down. Validate their experience and use encouragement to foster change. NSSI is a form of communication. A client using it is in emotional pain; make sure the therapeutic environment invites them to communicate that pain differently.”

Finally, it’s important for counselors to understand that NSSI is how these clients are coping, she says.

“While this behavior is sometimes scary due to its relationship with suicide (especially in adolescence), it’s helpful to think about this for what it is—a maladaptive coping strategy. Help the client to think about their life without it (e.g., “If you imagine yourself 10 years front now, do you think you’ll still need self-injury in your life?”), help them develop the belief that they can control this behavior—that there are other strategies they can use that will work, help them to develop the language to talk about its role in their life, and ultimately, make sure you are coming into session curious, with a desire to understand.”

Amanda C. La Guardia, PhD, NCC, LPCC-S, is licensed to practice as a professional counselor in Ohio and is a National Certified Counselor, Certified Clinical TeleHealth Provider, and Certified Clinical Trauma Professional. She received her bachelor’s degree in biology and psychology with a minor in criminal justice from East Tennessee State University (ETSU), her master’s with a dual concentration in marriage and family counseling and community counseling from ETSU, and her PhD with an emphasis in research and statistics from Old Dominion University. She also completed a graduate teaching certificate in women’s studies. Her clinical experience includes in-patient expressive arts group work and outpatient family and individual counseling with youth transitioning into or out of the foster care system. She also has experience running outpatient adolescent substance abuse groups, including holistic assessment of adolescent SUD. 

**Opinions and thoughts expressed in NBCC Visions Newsletter articles belong to the interviewees and do not necessarily reflect the opinions or practices of NBCC and Affiliates.