Self-Injury Workshop Summary
Part 1 – Self-Injury vs. Suicidality

By Lynn Mollick

On Sunday, June 6 Dr. Barent Walsh presented an NJ-ACT Zoom workshop “Assessment and Treatment of Non-Suicidal Self Injury (NSSI).” According to Dr. Walsh, NSSI is “intentional, non-life threatening, self-effected bodily harm or disfigurement of a socially unacceptable nature, performed to reduce emotional distress and/or effect change in others.”

NSSI and Suicide are Two Distinct Problems

Suicide’s purpose is to end misery permanently. NSSI’s purpose is to temporarily reduce emotional distress and secondarily to affect others. Suicidal patients experience hopelessness and helplessness. NSSI patients experience their self-injury as a form of control.

Suicide is uncommon, occurring successfully in less than 1% of the population. NSSI is common. A 2015 CDC study found that 17.6% of high school students committed NSSI at least once during the previous year.

Suicidal patients usually plan to use one method; considering more than one method puts a patient at higher risk. NSSI patients usually practice many methods and readily switch or develop new methods.

If a patient has both problems, treat suicidality first and treat NSSI after suicidal impulses are under control. For suicidality, remove opportunity and means. Removing opportunity and means for NSSI is not effective because these patients readily switch to alternative methods of self-injury.

NSSI Predicts Suicide Attempts

Klonsky, et al. (2013) found the following correlations between various diagnoses and suicide attempts:
.36 NSSI
.29 Borderline personality disorder
.24 Depression
.16 Anxiety
.11 Impulsivity

NSSI may prepare patients for suicide by reducing the fear of pain associated with taking one’s life. Intervene early in treatment to prevent the emergence of suicide attempts.

Developing a Functional Analysis

Do a thorough functional analysis of specific incidents of NSSI:

• Explore situational, psychological (thoughts, feelings, behaviors) and biological (drugs, hunger, fatigue) antecedents of self-injury.
• How strong was the urge to self-injure?
• How long did the incident last? What was the motivation to stop?
• What did the injury look like? Where was it on the body? One wound or several?
• What tool did they use?
• How much pain did the patient experience?
• What were the consequences of the self-injury? What thoughts and feelings did the patient experience? How did others respond? Was medical intervention needed?
• Understand the reinforcement for each NSSI incident. Negative self-reinforcement is the most common function of NSSI. (“I get relief from dysphoric emotions.”) Positive reinforcement – “my parents pay attention” – is less common. Positive self- reinforcement – “I get high from self-injuring” – is rare.

During your interview, be low-key and dispassionate. Adopt a respectful and curious manner. Be compassionate, but avoid offering too much support. Support might inadvertently reinforce NSSI.

Use the patient’s vocabulary and avoid technical or pejorative language such as “borderline” or “self-mutilation.” Unless it would be immodest, ask to see the injury. Is the patient proud or ashamed?

Ask: “Besides [cutting], what else do you do?” Be specific and get details. Although it is not necessary to develop an exhaustive list of self-injurious behaviors, keep in mind that different forms of NSSI often regulate different emotions.

Dr. Walsh insists on the use of paper-and-pencil assessments. They pose questions an interviewer may not, and they provide measurable data to monitor progress. Dr. Walsh recommends the FASM – Functional Assessment of Self-Mutilation which is available here.