Self Injury

Non-Suicidal Self-Injury Behavior among Adolescents: Assessment Methods and Intervention Strategies

Abstract

Counselors are increasingly faced with the task of responding to non-suicidal self-injury (NSSI) behaviors among clients. Mental health counselors must be able to adequately and efficiently identify the behavior and determine the course of action that will best support the client. This paper provides counselors with an overview of assessment methods that may facilitate decision making when working with adolescents who self-injure, with particular attention given to three scales with preliminary evidence for psychometric adequacy. The authors also discuss intervention strategies that may be especially helpful when counseling these adolescents.  Finally, areas for continued research are discussed.

Non-Suicidal Self-Injurious Behavior among Adolescents: Assessment Methods and Intervention Strategies

     Non-suicidal self-injury (NSSI) behavior is defined as deliberately physically harming one’s body without intent to end one’s life (Andover, Pepper, Ryabchenko, Orrico, & Gibb, 2005; Muehlenkamp, 2006; Wester & Trepal, 2005) and although there is no distinct classification for NSSI in the current DSM-IV-TR, there are certain agreed-upon behaviors that are included in this specific syndrome (Adler & Adler, 2005). Self-cutting appears to be the most common form of NSSI among both males and females (Nock & Banaji, 2007; Yip, 2006). Although estimates differ throughout the literature, they usually range from 15% to 39% of middle and high school students who participate in NSSI with 12 to 15 years of age being the usual age of onset (Nixon & Heath, 2009). Given the high prevalence of the behavior and the usual age of onset, it is no wonder that mental health workers often encounter clients who engage in the behavior. Although NSSI is certainly not a new behavior (Conterio & Lader, 1998; Moyer, 2005), there is evidence that the act of destroying one’s own body tissue has been increasing among adolescents (Fortune, Sinclair, & Hawton, 2010; Hoffman & Kress, 2008; Muehlenkamp & Gutierrez, 2004; Muehlenkamp, Walsh, & McDade, 2010), and therefore awareness and concern have intensified over the past few years (Woldorf, 2005). As evidence of this growing concern, the literature base concerning self-injurious behaviors has increased dramatically over the past decade.

     Understanding how to assess clients’ behaviors and work with them appropriately or refer out to others is important when interacting with all clients, but even more so when addressing issues as complex and risky as self-injury. Counselors have an array of resources from which to pull in order to provide psycho-educational materials and intervention strategies to clients regarding this specific behavior. One area, however, that has not received as much attention in the literature is the need for evidence based, clinically relevant, and psychometrically sound assessment tools that may be helpful in measuring NSSI and in determining the difference between self-injury and suicide-related behaviors (Walsh, 2007). Several instruments designed to measure these behaviors will be described in this paper, with particular attention given to the preliminary psychometric support for these instruments. We also will provide a review of specific best practices for working with children/adolescents who self-injure. Before discussing these issues, we begin with a brief review of the recent literature on NSSI that has explored the reasons, precursors, and explanations for self-injurious behaviors.

Self-Injurious Behavior in Adolescents

     As mentioned previously, self-injury is usually first experimented with during the adolescent years (Nixon & Heath, 2009). Adolescence, often defined as ages 12-18, represents a developmental transition between childhood and adulthood. It is characterized as a time of rapid change not only in physical appearance, but also in psychological and social functioning (Yip, 2006), and is a time that many teens strive towards gaining control and autonomy over their bodies and lives (Corey, 2005). Self-injury can serve as a maladaptive expression of this developmental task, as well as a means for communicating emotions and feelings, reducing anxiety and tension, or being accepted by peers (Nichols, 2000).

     Self-injury may initially be performed sporadically; however many times the behavior becomes habitual and can even take on addictive qualities which make it difficult to discontinue (Crowe & Bunclark, 2000; Huband & Tantam, 2004). Clients who continue self-injury past the first episode may do so for several different reasons. One common reason for continuous self-injury is the positive feelings associated with the behavior such as release of tension and/or temporary relief from trauma and overwhelming life situations (Lloyd-Richardson, 2010). The peaceful feeling following the action has been compared to the tranquility sometimes felt by the use of drugs or during a religious encounter (Adler & Adler, 2005). These perceived positive effects normally last for varying lengths of time ranging from up to 24 hours (Crowe & Bunclark, 2000) to several days (Adler & Adler, 2007).

     Clients may experience a feeling of relief after the pain of self-injury while others may report an inability to feel pain at all (Winchel & Stanley, 1991). Feelings of numbness can occur both before and after the behavior. The behavior can also be an attempt to offset this lack of sensation (Nevid, Raathus, & Greene, 2006), and restore clients’ confidence that they are still alive (Lloyd-Richardson, 2010; Winchel & Stanley, 1991). Clients increase the intensity and seriousness of the self-inflicted behavior to encourage physical sensation, as the satisfaction achieved through NSSI may diminish after repeatedly engaging in the act (Alderman, 1997).

     Additionally, adolescents injure themselves in numerous ways. Some proudly display their wounds, while others desperately attempt to hide injuries from friends and family members and injure more concealed parts of their body (Adler & Adler, 2007). Many clients who engage in self-injury appear well-adjusted (Crowe & Bunclark, 2000), and in the absence of physical evidence it may be difficult to distinguish between those who participate in NSSI from those who do not. In addition to distinguishing those who self-injure from those who do not, counselors have a difficult task of determining the severity and function of the behavior once it is identified. While some behaviors may simply reflect maladaptive coping methods, other clients may be engaging in self-injury with the intention of doing more severe and permanent harm to themselves.

Distinguishing between Suicide Attempts and NSSI

     In the past many have considered suicide and self-injury to be very similar behaviors, because the behaviors themselves and outcomes (e.g., wounds) are often similar. Although at times it can be challenging to distinguish between a suicide attempt and less lethal NSSI (Alderman, 1997), there is now a recognized distinction between the motives or functions behind these behaviors (Muehlenkamp & Kerr, 2010). The term self-harm does include acts such as attempted suicide, but NSSI is generally performed to help the individual stay alive by coping with stress or emotional pain (Wester & Trepal, 2005). Thus, suicide attempts are efforts to end life, whereas people who perform NSSI are using maladaptive coping strategies to manage difficulties and sustain life (Muehlenkamp & Gutierrez, 2004). Some researchers view NSSI as a way to keep from resorting to even more harmful ways of coping with the world (Adler & Adler, 2005).

     Even though NSSI is viewed as a non-suicidal form of self-harm, some individuals who engage in NSSI may ultimately attempt and/or commit suicide (Nichols, 2000). In fact, research shows that individuals who participate in NSSI have twice the risk for death as those who do not participate in self-injurious behaviors (Oldham, 2006). This may be attributed either to a decision to end life instead of coping with stressors, or to accidentally taking the behavior too far resulting in unintentionally fatal wounds (Nichols, 2000). Connors (2000) found that 45% of individuals who had committed suicide had a previous history of self-injurious behaviors, although the distinction between previous suicide attempts and non-suicidal self-injurious behavior was difficult to determine. It is also interesting to note that an estimated 28%-41% of people who utilize NSSI as a coping strategy have a history of at least one suicide attempt, although the specific method used to end their life is generally different than the coping method used to sustain life (Muehlenkamp & Gutierrez, 2004). Thus, although there is an association between NSSI and suicide attempts, NSSI does not provide an inevitable pathway to suicide attempts. 

Assessment of Function and Risk

     Trepal and Wester (2007) surveyed 1000 members of the American Mental Health Counselor’s Association and 81% of the counselors reported that at least one of their clients has participated in NSSI without the intent to die. Even when self-injury is not the presenting concern, all clients should be assessed for NSSI at intake, and it is important that counselors not make generalized assumptions concerning clients’ visible injuries or verbal comments (Connors, 2000). Since injuries may appear similar in both a suicide attempt and NSSI, if the counselor stereotypes clients based upon physical lesions instead of taking the time to thoroughly assess the client, an incorrect diagnosis and non-effective treatment plan may be initiated. In addition, the client’s disclosure of their reason for partaking in the act may be different from the true meaning behind the behavior. Therefore, results of the assessment should be carefully evaluated and interpreted in order to accurately diagnose the individual and establish the lethality of the behavior (White Kress, 2003). It is critical to differentiate between suicidal ideation and utilizing NSSI without the intent to die, because each will lead the counselor in different directions with regard to immediate responses and long-term intervention. Also, clients who self-injure may share instruments (e.g., blades, needles) with others, thereby increasing the possibility of spreading diseases and infections, which may warrant both psychoeducational and medical evaluation (White Kress, 2003).

     There are numerous formal evaluation tools to help in assessing NSSI, including the Self-Harm Behavior Survey (Favazza & Conterio, 1988), Self-Injury Trauma Scale (SIT; Iwata, Pace, Kissel, Nau, & Farber, 1990), Self-Injury Questionnaire (SIQ; Santa Mina et al., 2006), Deliberate Self-Harm Inventory (DSHI; Gratz, 2001), Self-Harm Behavior Questionnaire (SHBQ; Gutierrez, Osman, Barrios, & Kopper, 2001), Self-Harm Inventory (SHI; Sansone, Wiederman, & Sansone, 1998), and Self-Injury Implicit Association Test (Nock & Banaji, 2007). It should be noted that most of these instruments were developed as part of research studies examining various aspects of NSSI, such as functions of the behavior, classification of injury severity, and relationships between NSSI and other psychological constructs. Thus, the clinical utility of these measures has not been rigorously evaluated, and further research will be necessary to determine whether these instruments will facilitate accurate decision-making by professionals. Below is an overview of three instruments that demonstrate adequate psychometric properties (although preliminary), and that may provide counselors with useful information during the assessment process because these instruments go beyond looking at frequency and methods of NSSI; they also look at the functions or purposes of the behaviors for the individual, and in some cases may help the clinician make the distinction between NSSI and suicide-related behaviors. This description of available tools is intended for informational purposes only, and does not necessarily reflect endorsement. Further, the use of any of these assessment instruments requires appropriate training and credentials to administer, score, and interpret the instruments.

Self-Injury Motivation Scale

     The Self-Injury Motivation Scale (SIMS; Osuch, Noll, & Putnam, 1999) was initially designed in an effort to investigate reasons for, and functions of, NSSI among inpatients admitted to a psychiatric hospital. Participants in the study included 99 adult inpatients, most of whom were White. The SIMS was developed by consulting the literature on NSSI, resulting in 35 items, each of which asks the respondent to rate the frequency with which they self-injure in order to fulfill various functions (e.g., to control emotions, to gain attention from others). It should be noted that the SIMS does not include items about suicide as a motivating factor for engaging in NSSI and thus may not be a strong instrument for differentiating between the two behaviors. Frequency is measured with a 10-point scale ranging from 0 (never) to 10 (always). Several psychometric analyses of the SIMS were conducted using study data. For example, coefficient alpha based on all 35 items was .96. Test-retest stability was .70 based on a subsample of 32 participants who completed the SIMS on two separate occasions, with an interval ranging from 2.5 to 11 weeks. Exploratory factor analysis was used to create the following subscales based on item groupings: Affect Modulation, Desolation, Punitive Duality, Influencing Others, Magical Control, and Self-Stimulation. Alpha coefficients for these subscales ranged from .81 to .93. Further, evidence for convergent validity was provided by correlating scores on the SIMS with scores on other measures. SIMS scores were correlated with depression as assessed with the Beck Depression Inventory (r = .60), and also showed associations with some of the psychopathology subscales on the Millon Clinical Multiaxial Inventory – II (e.g., Borderline, Avoidant, Self-Defeating). Based on the results of this initial analysis, 1 item was deleted from the SIMS and 2 were added, resulting in the 36-item SIMS Version 2. A copy can be downloaded at: “http://www.centerforthestudyoftraumaticstress.org/downloads/SIMS_ver2.pdf”.

     Although the psychometric properties of the SIMS are generally favorable, the development of the instrument is limited by the use of a small sample in the psychometric analyses, as the sample included only 99 people, all of whom had been hospitalized. Thus, results are limited to adult psychiatric inpatients and the psychometric characteristics may change drastically when the scale is used with non-hospitalized adolescents; the factor analytic results are especially tenuous given the relatively small sample size. Results are also limited by incomplete information regarding the development of the cutoff scores used to classify participants as high or low SIMS scorers; in the absence of such information, similar classification in clinical settings is likely to be of little utility. At the same time, this scale may help counselors identify the functions served by NSSI behaviors which would hold important treatment implications. For example, an adolescent who reports using NSSI as a form of self-punishment would likely need different intervention approaches than an adolescent who uses NSSI to express their emotions, or to gain attention from others, or to provide self-stimulatory sensations, and so on. Within this context, the SIMS may help the clinician narrow down and then address the multiple potential functions of NSSI behaviors, but additional research will be necessary to establish the relevance of the scale with adolescents.

Functional Assessment of Self-Mutilation

     The Functional Assessment of Self-Mutilation (FASM; Nock & Prinstein, 2004; Penn, Esposito, Schaeffer, Fritz, & Spirito, 2003) is a self-report instrument that examines the methods of self-injury used in the previous 12 months, the frequency of the behavior, and the functions it serves for the client. The content of the FASM is based on the literature on NSSI among adolescents and on information gained through interviews with adolescents who reported engaging in NSSI behaviors (Lloyd, 1998, as cited in Nock & Prinstein, 2004). Unlike the SIMS, the FASM was developed and evaluated using samples of adolescents, thereby making the relevance of this instrument to adolescent clients more clear. The 11 methods included on the FASM consist of cutting/carving skin, picking at a wound, hitting self, scraping skin to draw blood, biting self, picking skin to draw blood, inserting objects under skin, tattooing self, burning skin, pulling out own hair, and erasing skin to draw blood. Similar to the SIMS, the FASM also contains 22 possible functions of the NSSI behaviors, allowing examinees to indicate frequency of reasons for engaging in these behaviors (using a scale from 0 to 3).

     The FASM has been tested with psychiatric adolescent samples. In one study (Penn et al., 2003), the FASM was used as a measure of NSSI behaviors among a sample of adolescents incarcerated in a juvenile correctional facility. Of the 289 adolescents sampled, 78 were referred for a psychiatric evaluation which included the FASM; data from these 78 adolescents were used to examine psychometric properties. Interestingly, the authors asked the adolescents to complete the FASM twice: once within the context of engaging in NSSI during the year prior to their incarceration, and once within the context of engaging in these behaviors during their incarceration. Coefficient alpha was found to be .86 for both time periods, indicating adequate internal consistency. Among this sample of adolescents, the most frequently endorsed functions of NSSI as assessed by the FASM involved regulating feelings and self-punishment. Unfortunately, correlational analyses were not conducted in order to examine whether FASM scores were correlated with scores on other measures used in the study (e.g., measures of depression, anger, anxiety), which might have provided preliminary evidence for construct validity.

     In another study using the FASM, Nock and Prinstein (2004) examined the psychometric characteristics of the instrument with a sample of 108 adolescent psychiatric inpatients. Based on expert consensus and confirmatory factor analysis, the authors developed and tested four subscales for this instrument: automatic-negative reinforcement, automatic-positive reinforcement, social-negative reinforcement, and social-positive reinforcement; these subscales are consistent with the authors’ hypothesized categories of NSSI functions and suggest that functions can be categorized based on whether they are self-reinforcing, socially-reinforcing or both self and socially reinforcing (Nock & Prinstein, 2004). Thus, adolescents may engage in NSSI to decrease tension or negative emotions (automatic-negative reinforcement), increase positive feelings (automatic-positive reinforcement), avoid social settings or demands (social-negative reinforcement), or gain access to other people or attention from other people (social-positive reinforcement). Alpha coefficients for these four factors ranged from .62 to .85; three of the factors have very few items (i.e., 2, 3, and 4 items), which likely accounts for lower alpha coefficients. The most frequently-endorsed function was automatic-negative reinforcement, which involves using NSSI to stop or relieve negative feelings. Although the findings from both of these studies are promising, the FASM needs to be studied with larger samples of non-hospitalized and non-inpatient samples of adolescents, in order to determine whether the psychometric properties and factor structure can be replicated. As with the SIMS, the FASM appears to hold intuitive appeal for counselors by providing a systematic way of assessing frequency and function of NSSI behaviors.

Suicide Attempt Self-Injury Interview

     In contrast to the SIMS and FASM self-report scales, the Suicide Attempt Self-Injury Interview (SASII; Linehan, Comtois, Brown, Heard, & Wagner, 2006) is a structured interview that collects detailed information concerning suicide attempts and NSSI. The SASII attempts to distinguish suicidal intent from other functions, in order to determine whether intervention for suicidal ideation and intent is necessary. Thus, the SASII looks at method of self-injury; intent of the behavior; lethality or severity of the behavior; environmental, interpersonal, and behavioral factors surrounding the behavior; and consequences that may be maintaining the behavior. These represent useful features of the SASII, as they can help the counselor discern the functions of NSSI behaviors.

     The interview begins by completing a timeline with the examinee, in which all NSSI episodes over the past year are documented. The SASII then incorporates fixed-response and open-ended questions that allow the clinician to gather detailed information about each episode in order to make the distinction between suicide ideation and attempts from NSSI. Items were developed through consultation of the suicide and self-injury literature, and by examining other measures of suicidal behavior. Items were tested and revised using five different samples of adults with various psychiatric or medical issues. Subjective items demonstrated adequate interrater reliability (all above .84). Exploratory factor analyses conducted with combinations of these samples suggested that the SASII items could be categorized into four subscales: Suicide Intent (alpha = .93), Rescue Likelihood (alpha = .72), Suicide Communication (alpha = .63), and Lethality (alpha = .85). These factors are limited by a very small number of items on each subscale (2 to 4 items). Other scales are available on the SASII; these were rationally derived for the purpose of assessing examinees’ reasons for NSSI behaviors. These scales include Interpersonal Influence, Emotion Relief, Avoidance/Escape, and Feeling Generation; these subscales are similar to some of the functions of NSSI assessed by the SIMS and FASM. Based on all information gathered, the clinician classifies each self-injury episode as NSSI, an ambivalent suicide attempt, a suicide attempt with no ambivalence, or a failed suicide; these classifications demonstrated high interrater reliability at .92, suggesting that the behaviors can be categorized consistently by different clinicians. Among those participants classified into the NSSI group, the most frequent purposes of the behaviors included self-punishment, expression of anger, feeling generation, and escape.

     Although the SASII was developed for research purposes (in order to facilitate the accurate differentiation of NSSI and suicidal behavior), it provides a good example of how a structured clinical interview can be used in the assessment of NSSI, and also may demonstrate clinical utility due to its comprehensiveness. The SASII instrument and scoring instructions are available online at “http://www.brtc.psych.washington.edu/pubs/instruments.html”.

     In summary, and as previously stated, there exist numerous reasons why an adolescent may choose to participate in NSSI, and therefore it is extremely important that the counselor attempt to understand the true meaning and function behind the behavior. Similar behaviors may serve different functions for different people, meaning that counselors should take great care in identifying the meaning of each individual’s behavior and then choose the best option for treatment. From an operant conditioning perspective, knowing the functions of the behaviors should help counselors develop individualized treatment plans, as identifying factors that trigger and maintain the behaviors suggest very specific targets for intervention. Thus, assessment of NSSI should lead to individually-tailored interventions based on data that identify the antecedents, consequences, and, ultimately, the functions of the behavior. One of the attractive features of scales such as the SIMS and FASM, and structured interviews such as the SASII, is that these measures go beyond assessing frequency of symptoms to determining the functions of NSSI behaviors. Additional research on NSSI may lead to the development of norm-referenced instruments, which should facilitate intervention by providing norm-referenced perspectives on the purpose of NSSI behaviors, the severity of the behavior, the reason and timing of the onset, and the adolescent’s readiness for change.

Interventions and Best Practices

     Working with clients who participate in NSSI is both exhausting and emotional. Supervision and/or consultation with other professionals may assist in maintaining objectivity and effectiveness (Hoffman & Kress, 2008; White Kress, 2003). For some, discontinuing NSSI behaviors may be fairly easy, while for others, discontinuation may be more difficult and frustrating for both the client and his/her family (Strong, 1998). Some adolescents embrace professional assistance to stop the behavior, while others present with anger and resentment as they resist giving up this maladaptive yet effective coping method. Improperly addressing the NSSI can cause the adolescent to continue and possibly increase the behaviors (Yip, 2006). Treatment interventions include a myriad of modalities such as medical and psychiatric referrals, assessments, and more traditional counseling techniques. The professional literature is still incomplete in identifying best practices for working with clients who self-harm (Muehlenkamp, Walsh, & McDade, 2010), but there are similar characteristics among the techniques identified as being successful with this population. Materials presented in the previous section were intended to give counselors examples of appropriate means to assess the behaviors (including the function of the behaviors). The suggestions below are meant to provide counselors with strategies to maximize their effectiveness when working with adolescents who self-injure.

Establish the Therapeutic Alliance

     Building strong therapeutic alliances with clients is imperative. Research indicates the counselor/client relationship can be as healing as other counseling interventions used when working with adolescents who participate in NSSI (Muehlenkamp, 2006). Although a positive alliance is beneficial in all counseling situations, with clients who utilize NSSI, the relationship may be especially important (Moyer, 2005). While seemingly simple, many mental health professionals lose sight of this basic concept when confronted with the cuts, scratches, burns, and blood associated with NSSI. Connors (2000) identified a lack of understanding, feelings of inadequacy, liability concerns, compassion fatigue, countertransferance, and feeling helpless as issues that contribute to counselors forgetting their basic helping skills. When counselors focus on the behavior instead of the individual they may come across as insincere, judgmental, and uncaring.

     Adolescents who practice NSSI are often exposed to ridicule, shame, and embarrassment due to their behaviors and thus a solid trusting relationship is a must. Moyer and Nelson (2007) noted that many individuals who self-injure just want to be heard and listened to without being judged. Adolescents identify having someone to talk to and having someone who will listen to them and give them support as key components in preventing further self-harm (Fortune, Sinclair, & Hawton, 2010). Therapeutic suggestions based on clinical experiences include holding positive beliefs about the client’s potential, being respectful of cultural differences, and showing empathy, genuineness, and reverence towards each and every client. Implementing Rogers’ necessary and sufficient conditions for change (Rogers, 1957) are imperative. Simply discussing the issue with clients, focusing on the necessary and sufficient conditions, and respectful curiosity about NSSI can be therapeutic (Moyer & Nelson, 2007). Devoting the time and attention necessary to understanding the adolescent’s perspective and the purpose that NSSI fulfills for them is essential.

Determine the Reasoning behind the Behavior

     Some clients may openly and accurately express the reasoning behind their self-injury. Others may not be aware of the purpose and meaning that it serves in their life (Oldham, 2006). Through respectful questioning counselors can help clients identify the fundamental cause of NSSI, rather than categorizing all together (White Kress, 2003). The same behavior can serve very different functions among clients. Self-punishment, distraction from problems, reducing depression and/or anxiety, a way of communicating emotions, to end dissociation and to overall feel better have all been identified as reasons why adolescents may injure themselves (Alderman, 1997; Gratz & Chapman, 2009; Laye-Gindhu & Schonert-Reichl, 2005; Moyer & Nelson, 2007; Strong, 1998). This variety in functions may take the counselor in diverse treatment directions. Questions exploring client emotions before, during, and after the act, patterns of stressors or events that may lead up to NSSI and significant childhood experiences help to identify the behavior’s primary function (White Kress, 2003). Note that these procedures are quite similar to those discussed in the assessment section, illustrating how assessment and intervention are often part of the same overall process: assessment should drive intervention, and sometimes the assessment process itself serves therapeutic purposes.

Address Thoughts and Beliefs

     Negative thinking and self-talk messages can exacerbate the effects of maladaptive coping mechanisms. Low self-confidence and a negative opinion of oneself are both common attributes of those who self-injure (Gratz & Chapman, 2009; Laye-Gindhu & Shonert-Reichl, 2005; Muehlenkamp, 2006). In addition, since others have physically or sexually taken control over their bodies, those with an abusive childhood history may exhibit poor interpersonal boundaries (Alderman, 1997). As part of addressing NSSI, counselors can explore and challenge (at the appropriate stage) thoughts and beliefs with the client. The goal is to increase self-understanding, self-confidence, and self-respect (Connors, 2000; Walsh, 2007). Beyond addressing negative thinking, beliefs, and self-talk, counselors may use Solution-Focused techniques such as focusing on the positive aspects of the adolescent’s life. Doing so involves developing appreciation for the favorable parts and contemplating what positive lessons the adolescent has learned as a result of going through past difficult experiences. Ultimately, the client becomes aware of specific thoughts, feelings, and situations that may trigger the desire to self-injure.

Address the Behavior

     Addressing the behavior involves increasing awareness. Although the adolescent may not be able to control life situations, he/she can control the way they choose to deal with stressful or negative events. Using operant conditioning principles, it might be helpful to collaborate with the client and develop a list of reinforcements or alternate, less destructive behaviors that can be used to reduce the frequency or severity of the NSSI (Muehlenkamp, 2006; Wester & Trepal, 2005). Alternate activities will differ with each individual but may include using artistic expression to convey emotions, physical exercise, marking on the skin with markers to simulate cutting the skin, singing, dancing, journaling, and/or self-monitoring. Moyer (2008) discusses a Safe Kit in which several of the above mentioned activities are combined in order to provide clients with a tool kit of alternate activities to turn to when they feel like harming themselves.

     Similarly, identifying triggers or antecedents to NSSI allows counselors and clients to choose interventions that may be most appropriate. These include strategies for modifying environmental or cognitive variables that trigger the behavior or modifying consequences that reinforce and therefore maintain the behavior. Muehlenkamp (2006) proposed emotion regulation skills as an important component of NSSI interventions. Thus, skills in coping, stress management, and emotion regulation can be taught. Role-play during individual meetings can be used as a way to practice and internalize the above-mentioned behavioral techniques. Finally, Alderman (1997) suggests encouraging clients to dispose of any NSSI tools so that they are not readily available when stressful events arise.

Strengthen the Support System

     A critical task for counselors working with NSSI is to help clients strengthen or build support systems. The responsibility of building support systems is confounded by stigma associated with NSSI. Recent literature (Froeschle & Moyer, 2004; Gratz, Conrad, & Roemer, 2002; Yip, Ngan, & Lam, 2003) notes that adolescents who self-injure may have difficulty forming attachments with others, have frequent peer conflicts, have ineffective communication with their family and in particular may have a strained or difficult relationship with their primary caregivers. Concomitantly, friends and family members often misunderstand the purpose of the behavior resulting in further judgment and ridicule.  Promoting overall education and awareness within family, friends, and community groups is considered a critical component of preventing NSSI (Fortune, Sinclair, & Hawton, 2010).

Conclusion

     For some clients, adolescence represents a time of conflict. It is a time to discern between parental values and one’s own values (Miller, 2002). The process can be painful and confusing at times, and may result in the adoption of some maladaptive coping mechanisms such as NSSI behavior. The information above provides counselors with two valuable resources useful in helping clients who self-injure. First, materials are provided regarding assessment tools that can be helpful in properly assessing a client’s behaviors. In order to provide adequate services and/or referral, the counselor must know what they are working with and the unique function of NSSI behaviors. Second, general strategies are provided for mental health professionals to use when working directly with adolescents who self-injure. Perhaps the strategies described here will provide some additional structure and guidance for professionals who may lack confidence in their skills to address the issue properly.

Additional research is desperately warranted so that all mental health professionals are able to increase their effectiveness when working with this population. Such research should include refining current and developing new assessment measures, exploring novel intervention approaches, conducting efficacy or effectiveness studies, and establishing more focused and specific empirically-supported treatments. While empirically-supported or “manualized” treatments have been identified for a range of childhood and adolescent psychological and behavioral disorders (e.g., anxiety, depression, oppositional defiant disorder), such intervention approaches for NSSI among children and adolescents have not yet been well-established (see Muehlenkamp, 2006). Similarly, many online assessment instruments available through various organizations have not been well-normed or validated, which suggests caution in relying on these tests for clinical decision making. At the same time, this paper has presented counselors with assessment and intervention approaches that show promise. It is hoped that future inquiry will provide additional guidance for mental health professionals as they strive to help clients who self-injure enhance their skills for coping with stressful situations and their environment.

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