One day, I had an intake session with a new client – a woman I had never met before. She came to me that day, seeking treatment for her heroine addiction. As part of the intake, I asked her specific questions regarding her heroin use, as well as other assessment questions, in order to determine the level of her addiction, help identify underlying issues contributing to her heroin use, and aide in crafting a treatment plan that would be effective in helping her overcome this addiction. One of the other questions I asked was in regard to self-harm. I asked this question even though there had not been any evidence or indication that self-harm was an issue.
When I asked the woman if she had ever tried to harm or inflict injury on herself, she became very emotional. She confessed to me that she had cut herself very badly, just the night before. She then raised her shirt sleeves to reveal multiple zig-zagging cuts along the length of each arm that had been made with a razor. She explained that she had been in an argument with her husband the day before. After the argument, she was in such emotional distress that the drugs that she normally took to numb her emotions had not been effective, so she cut herself in an attempt to find relief. She was very ashamed of what she had done and admitted that if I hadn’t specifically asked her, she would not have mentioned that she engages in this type of behavior as often as once a month.
My new client was not only using drugs to cope with her emotional issues, but also inflicting injury to herself (NSSI) – two very disturbing and dangerous behaviors. She needed my help.
Nonsuicidal self-injury (NSSI) can be defined as “directly and intentionally inflicting damage to one’s own body tissue without intention of suicide and not consistent with cultural expectations or norms.”1 NSSI is commonly confused with “self-harm”, however there is a distinct difference between the motives and functions of the two. Self-harm includes attempts of suicide, but NSSI does not. Although a person engaging in NSSI may accidentally inflict a fatal wound that unintentionally ends their life, it is believed that NSSI behavior is actually a maladaptive coping mechanism to sustain life as a way to cope with stress and emotional pain.2 The most common method of self-injury is cutting (45-70%), however other common methods include burning, battery (punching, hitting, bone-breaking), biting, pinching, skin carving, severe skin abrading, picking at sores to prevent healing, or plucking hair.
Even though NSSI is not intended to be a suicidal action, it has been found that people who engage in 20 or more NSSI behaviors are roughly 3.4 times more likely to attempt suicide compared to those who have fewer self-injury actions.3 The theory is that when people initially engage in NSSI they typically are not suicidal, but as the frequency of their NSSI behavior increases, it can lower their ability to combat suicidal thoughts and thus raise their risk of suicide.
The question many people might ask is, “Why would people deliberately harm themselves?” According to National Alliance of Mental Illness (NAMI), “The urge to hurt yourself may start with overwhelming anger, frustration or pain. When a person is not sure how to deal with emotions, or learned as a child to hide emotions, self-harm may feel like a release. Sometimes, injuring yourself stimulates the body’s endorphins or pain-killing hormones, thus raising their mood. Or if a person doesn’t feel many emotions, they might cause themself pain in order to feel something “real” to replace emotional numbness.”4
NSSI is most prevalent in adolescents and young adults, with typical onset between 11 – 15 years of age. According to an international meta-analysis of 52 studies, conducted by psychologist Jennifer Muehlenkamp, PhD, of the University of Wisconsin–Eau Claire and colleagues (Child and Adolescent Psychiatry and Mental Health), about 17% of adolescents had engaged in NSSI at least once. However, the lifetime rate for adolescents is between 15 – 20%. The lifetime rate for adults is much lower at 5-6%.3
NSSI can be found in all demographics, regardless of race, gender, religion or socioeconomic status. However, there seems to be an increased risk in individuals with a history of abuse, sexual trauma, eating disorders, borderline personality disorders, post-traumatic stress disorder, substance use disorders, depression, and anxiety.
If you or someone you know is struggling with NSSI or any other type of self-harming behavior, please seek treatment. There are several treatment methods that have proven to be effective in treating these destructive behaviors - from Dialectical Behavior Therapy (DBT), Emotion Regulation Therapy (ERT), Cognitive Behavioral Therapy (CBT), Dynamic Deconstructive Psychotherapy (DDP), as well as select pharmaceutical options.5 The most important thing is to reach out to a licensed mental health professional or medical doctor for help and they will guide you towards a treatment option that will work best for you and your unique situation.
With the woman I introduced at the beginning, we actually prioritized her NSSI, over her heroin addiction, in her treatment plan. While we worked on both issues simultaneously, the focus remained first and foremost on NSSI. Through the course of her counseling, it was discovered that a history of trauma had led her adopt these destructive behaviors as a way of coping with unpleasant emotions. Unfortunately, she had lacked the skills needed to be able to regulate her own emotions and to tolerate her own distress.
Through Dialectical Behavior Therapy (DBT), I was able to teach her how to recognize her emotions as well as skills to regulate those emotions and cope with distress when it arises. DBT proved to be very effective for her. Her last reported incident of self-harm was the one that happened the night before we met - that very first time. And although it didn’t happen right away, over the course of time, these same types of skills also helped her to overcome her daily use of heroin. She was able to find sobriety and ultimately an entirely new life.
 Westers NJ, Muehlenkamp JJ, Lau M. SOARS model: risk assessment of nonsuicidal self-injury. Contemporary Pediatrics. July, 2016. http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/soars-model-risk-assessment-nonsuicidal-self-injury. Accessed April 17, 2017.
 Non-Suicidal Self-Injury Behavior among Adolescents: Assessment Methods and Intervention Strategies. shsu.edu. Accessed December 8, 2020. https://www.shsu.edu/piic/Self-injury
 Who self-injures?. American Psychological Association. Accessed December 8, 2020. https://www.apa.org/monitor/2015/07-08/who-self-injures.
 Self-harm. National Alliance on Mental Illness. Accessed December 8, 2020. https://www.nami.org/About-Mental-Illness/Common-with-Mental-Illness/Self-harm
 2011. Treating Nonsuicidal Self-Injury: A Systematic Review of Psychological and Pharmacological Interventions. National Center for Biotechnology Information. Accessed December 8, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4244876/