CCPR: Welcome, Dr. Flaherty. How do you distinguish non-suicidal self-injury (NSSI) from other types of self-harm?

Dr. Flaherty: I separate self-harm into unintentional self-harm, self-injurious behavior, non-suicidal self-injurious behavior, attempted suicide, and completed suicide. NSSI is intent to harm without wanting to die. This includes burning, cutting, head banging, or punching a wall. NSSI differs from unintentional self-harm, where we might see an adolescent with developmental challenges bang their head, slap themselves, or pick at their skin—those cases may result from frustration or anxiety, but they aren’t seeking to feel the pain.

CCPR: What is the relationship between NSSI and suicidal thoughts and behaviors (STB)? Is NSSI a risk factor for suicidality? Can they coexist?

Dr. Flaherty: A significant number of adults and adolescents report a history of both behaviors (Andover MS et al, Child Adolesc Psychiatry Ment Health 2012;6:11). However, the association between the behaviors is complex. NSSI and STB have unique risk factors, and although NSSI is associated with myriad negative consequences, a developing body of research suggests that NSSI may increase the risk for attempted suicide. We need to identify and treat NSSI, and we also need empirically supported prevention programs.

CCPR: How common is NSSI in kids and adolescents?

Dr. Flaherty: In a 2017 study, the prevalence range of NSSI was 7.5%–46.5% for adolescents, 38.9% for university students, and 4%–23% for adults (Cipriano A et al, Front Psychol 2017;8:1946). We don’t know if these numbers have changed with the pandemic. The first incident usually occurs around age 12 or 13.

CCPR: Why do kids engage in NSSI?

Dr. Flaherty: Often the adolescent is in emotional pain but feels they can’t control the situation. NSSI is an action they can take. The opposite also happens, where the teen is emotionally numb and harming is their way to feel something. In either case, there’s relief once they feel the pain. Other adolescents use NSSI to communicate pain, and some use it to punish themselves.

CCPR: How is NSSI related to borderline personality disorder (BPD)?

Dr. Flaherty: Until the early 2000s, NSSI was considered a symptom of BPD, and more females than males were diagnosed with BPD and NSSI. In 2015, the DSM-5 added non-suicidal self-injury disorder (NSSID) as needing further study but linked to depression and anxiety disorders. We don’t have statistics on how many depressed or anxious kids or teens engage in NSSI.

CCPR: Is there a difference in NSSI between males and females?

Dr. Flaherty: More females are reported with NSSI, possibly because male behavior looks different. Cutting and burning are common with females. Males tend to bang their heads, punch walls, or punch themselves (Ammerman BA et al, Psychiatry Research 2019;278:268–274). These behaviors might be minimized as “boys being boys” and underreported.

CCPR: Is NSSI different across cultural or racial groups?

Dr. Flaherty: Reports of NSSI are higher in White females, followed by Black and Hispanic females. These numbers may be skewed as minority populations may not receive care and go underreported. It’s important to note that self-injurious behaviors may be culturally appropriate. For example, tribal tattoos or memorial tattoos may have intention of pain and relief of emotions.

CCPR: How can we tell when a behavior is or isn’t NSSI?

Dr. Flaherty: It depends on the intention. Someone who pierces their ears because of aesthetics or who memorializes a loved one with a tattoo is not engaging in NSSI, but someone who pierces their ears because the pain of piercing makes them feel better is engaging in NSSI. If someone refuses food because of a distorted body image, that is not NSSI, but if they do it because the hunger pain makes them feel better, we categorize that as NSSI.

CCPR: Does social exposure play a role in NSSI?

Dr. Flaherty: It can. In adolescents, changes to brain regions called the “social brain” bring new perceptions and behaviors. Teens become more sensitive to facial expressions and social cues. There is also an increased sensitivity to social evaluation. The development of the social brain makes adolescents susceptible to peer pressure, but teens vary in their sensitivity to being influenced by others. This can result in maladaptive behaviors, such as substance use, sexual behaviors, and NSSI.

CCPR: Talk to us about the physical risks of continued NSSI.

Dr. Flaherty: For some, the self-harming behaviors will dissipate on their own, but for others, they can increase in severity like other addictive behaviors. There is a theory that NSSI releases endogenous opioids, reducing pain sensitivity, which can result in more episodes and increased severity to feel relief from the behaviors (Sher L and Stanley BH, Arch Suicide Res 2008;12(4):299–308). There is always a risk that the self-harm can result in infection or unintended death if the injuries are severe.

CCPR: How should we assess for possible NSSI?

Dr. Flaherty: Ask about it. Some mental health providers think asking about NSSI will put the thought in the patient’s head. That is wrong. When you ask about self-harm, your patient is more likely to trust you and talk about it. Asking screening questions is seven times more likely to discover NSSI as well as suicidal thoughts compared to not asking (AACAP, J Am Acad Child Adolesc Psychiatry 2001;40(7 Suppl):24S–51S).

CCPR: How should we approach the conversation?

Dr. Flaherty: Build up to it. Start with stress and distress: “How have things been going for you? Are there any increased difficulties for you right now? How do you normally manage these things?” Then, normalize NSSI and ask: “When people are experiencing distress, sometimes they’ll harm themselves. Have you ever done that or thought about doing that?” You’ve opened the door to say, “This is a safe place to talk.”

CCPR: What do you ask next if they admit that they are engaging in self-harm?

Dr. Flaherty: Sort out suicidal and non-suicidal intent and suicidal and non-suicidal behavior. Ask: “How are you self-harming?” Follow up by asking: “Have you thought about harming yourself so severely that you would end your life?” or “Have you thought about ending your life?” If the answer is yes, then you will need to clarify the details in a full suicide assessment and act accordingly to ensure safety, perhaps hospitalization.

CCPR: If the child is not acutely suicidal, what do we do next?

Dr. Flaherty: Ask how and when they self-harm. Many people engage in rituals with NSSI. They might keep their cutting implements, candles, or matches in a certain place, or turn on music and sit in a specific spot. Ask about how they feel before and after they self-harm. How often are they thinking about it—is it only when they’re angry or sad, or is it a constant thought? Most importantly, ask about lethality and severity. A person impulsively taking a kitchen knife to their wrist is doing something far more physically dangerous than using a safety pin on their leg. There may not be suicidal intent, but it may still require medical intervention.

CCPR: Are there semi-structured guides for asking about NSSI?

Dr. Flaherty: I prefer a more conversational approach. However, the book Treating Self-Injury has a review of formal assessments (Walsh BW. Treating Self-Injury: A Practical Guide. 2nd ed. New York, NY: Guilford Press; 2012). If you go over the assessments before the adolescent comes in, they can help you know what to cover.

CCPR: Is it important to see the injury?

Dr. Flaherty: This question is complicated, especially with telehealth. I do like to see it so I can assess for safety. I will not ask an adolescent to show me the injury if it requires removing clothing such as pants or is in a private area. If I’m able to see it, and it’s deep or looks infected, then they may need to go to the emergency department for medical attention—not because they’re suicidal, but because the injury needs to be looked at.

CCPR: How do you help the patient to talk with their parents?

Dr. Flaherty: I validate the teen’s concerns and use them as a therapeutic moment. I may say things like: “We need to tell your parents about this because we need their help to support you in finding better ways to manage the challenges in your life.” This includes all the details of the self-harming, what it is, how often they do it, etc. I prep the adolescent ahead of time so they know exactly what I will say.

CCPR: How do you talk about NSSI with parents?

Dr. Flaherty: Use a soft, calm tone of voice when speaking with them. For example: “Riley brought some heavy stuff to session this week, and as she was talking about her anxiety and her depression, she mentioned to me that one of the ways she copes is to self-harm. Now, I know that sounds scary, but it’s common with this age group, and we want to tell you what’s going on and what we can do to support her.” When we take these steps, parents feel engaged with us, and the adolescent doesn’t feel like we’ve betrayed them by breaking confidentiality. We need a long-term working relationship with both the parents and the adolescent. We also plan with the teen that if parents become upset, we will allow a space for that, and the therapist will take the lead in the session.

CCPR: What do you advise about sharp objects that the teen uses to cut remaining in the home?

Dr. Flaherty: When someone’s non-suicidal, I empower them to dispose of their self-harming instruments on their own, in front of the parent, rather than having the parent do a sweep of the room. This also helps the parent understand the adolescent’s ritual and see things better from the teen’s perspective, which in turn leads to better communication and problem solving as a team.

CCPR: Do you recommend parents do body checks to look for injuries?

Dr. Flaherty: In some situations, body checks may become necessary, but overall, body checks can complicate treatment. Self-harm doesn’t stop just because the teen has acknowledged it, and if it is set up as a bad behavior that needs policing, the teen is likely to try harder to hide it. So rather than checking for potential injuries, it’s better to involve parents in a plan of what they can do instead if there is an urge to self-harm.

CCPR: What does treatment look like for NSSI?

Dr. Flaherty: I take a two-pronged approach. First, I focus on harm reduction. The three most common harm reduction techniques for reducing NSSI are the rubber band technique, the ice cube technique, and the paper tearing technique. For the rubber band technique, we have the patient wear rubber bands around their wrist or ankle, if that’s where they’re self-harming; if they are starting to feel an urge to hurt themselves, they can snap the rubber band instead. The ice cube technique involves holding an ice cube to feel pain in a way that isn’t as dangerous as cutting or burning. Finally, the paper tearing technique can have similar cathartic effects as some self-harming behaviors. All three methods are intended to reduce harm as we explore the root causes of the intense emotions through talk therapy (Editor’s note: These methods are not meant to be used in lieu of more definitive treatment and need to be monitored as some patients will use them to continue self-harm (Wadman R et al, Arch Suicide Res 2020;24(3):384–401)).

CCPR: What kinds of talk therapy are helpful?

Dr. Flaherty: There are several therapies to address NSSI, including developmental group therapy (DGT), mentalization-based treatment for adolescents (MBT-A), dialectical behavior therapy for adolescents (DBT-A), and therapeutic assessment and brief intervention (TA). You can get training in these techniques to treat the patient yourself or refer out to someone else in your community (Flaherty HB, Child Adolesc Soc Work J 2018;35:85–95). DGT is for kids 12–18 and includes behavioral, dialectical, and social skills, as well as interpersonal aspects. MBT-A helps teens and families understand the role of feelings in behavior. DBT-A focuses on building skills and reducing maladaptive behavior. TA is a 30-minute treatment where the teen identifies the challenge, clarifies the motivation for change, and creates a letter with a plan for change.

CCPR: How else can clinicians support the treatment of kids and teens with NSSI?

Dr. Flaherty: The most important step is assessment. Conduct an in-depth assessment and develop a treatment plan to reduce the NSSI behaviors and address the underlying causes. While there are no definitive medications for NSSI, small studies suggest that medication is an option to treat co-occurring conditions such as depression, anxiety, posttraumatic stress disorder, and BPD in conjunction with psychotherapy (Turner BJ et al, Can J Psychiatry 2014;59(11):576–585).

CCPR: Thank you for your time, Dr. Flaherty.