Dr. Feder: Self-harm can be separated into different forms, including unintentional self-harm, self-injurious behavior, non-suicidal self-injurious behavior, suicide attempts, and completed suicide. Non-suicidal self-injury is the intent to harm yourself without wanting to die. This includes burning, cutting, head banging, or punching a wall. This is different from unintentional self-harm, where we might see adolescents with developmental challenges bang their heads, slap themselves, or pick at their skin. In this episode, we will discuss how to assess, discuss, and treat non-suicidal self-injury in children and adolescents.
Dr. Hanni Flaherty joins us today to help us unpack this topic. She is an assistant professor and chair of advanced clinical practice at Yeshiva University. She is also the president & clinical director of the Collaborative People Clinical Group in New York, NY.
Welcome to The Carlat Psychiatry Podcast.
This is another episode from the child psychiatry team.
I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice and the brand-new book, Prescribing Psychotropics.
Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice.
In a 2017 systematic review, the prevalence of non-suicidal self-injury was about 7.5%–46.5% for adolescents, 38.9% for university students, and 4%–23% for adults. The first incident typically occurs around ages 12 to 13. However, we do not know whether these numbers have changed with the pandemic.
With such high numbers, you might be wondering why non-suicidal self-injury is so common in kids and adolescents. Children are drawn to this behavior when they experience emotional pain but cannot control the situation. The opposite also happens: teens experiencing emotional numbness might harm themselves to feel something. In either case, there’s relief with the sensation of pain. Other adolescents use non-suicidal self-injury to communicate pain. And, some use it to punish themselves.
Dr. Feder, how is non-suicidal self-injury related to suicidal thoughts and behaviors (STB)? Is one a risk factor for the other? Can they co-exist?
Dr. Feder: A significant number of adults and adolescents report a history of both behaviors, however, the association between the behaviors is complex. Non-suicidal self-injury and suicidal thoughts and behaviors have unique risk factors and although non-suicidal self-injury is associated with a myriad of negative consequences, a developing body of research suggests that non-suicidal self-injury may increase the risk for attempted suicide. Mental health professionals need to identify and treat non-suicidal self-injury and we also need empirically supported prevention programs.
Mara: Dr. Flaherty, what conditions tend to be comorbid with non-suicidal self-injury?
Dr. Flaherty: Until recently, non-suicidal self-injury was considered a symptom of borderline personality disorder, and came with a gender stigma with more females than males diagnosed with borderline personality disorder and non-suicidal self-injury. In DSM-5, NSSI is also linked to depression and anxiety disorders. We don’t have statistics on how many depressed or anxious kids or teens engage in NSSI, but healthy, well-functioning adolescents do not self-harm as a way to cope instead of more adaptive coping strategies like exercise or talking with someone.
Dr. Feder: When determining whether a behavior is or is not non-suicidal self-injury, pay attention to the intention behind it. Someone who pierces their ears because of aesthetics or memorializes a loved one with a tattoo is not engaging in non-suicidal self-injury, but someone who pierces their ears because the act and the pain of piercing makes them feel better is. If someone is refusing food because of a distorted body image, that is not non-suicidal self-injury, but if they do it because the hunger pain makes them feel better, we categorize that as non-suicidal self-injury.
Dr. Flaherty, how do you differentiate non-suicidal self-injury in kids with developmental challenges who might engage in head banging, slapping themselves, or picking at their skin?
Dr. Flaherty: I would call that unintentional self-harm. They’re not necessarily thinking about it and planning it in the same ritualistic way that someone who is self-harming is. It seems aimpulsive, but they may not be making the decisions in the same sort of way due to their limitations, and they may doing it out of frustration or anxiety, but not seeking to feel the pain. That’s important to differentiate - the cause is very different. I separate self harm into unintentional self-harm, self-injurious behavior – non-suicidal self-injurious behavior and suicide attempts, and then successful suicide. Suicide could even fall under self-injurious behaviors, along with trichotillomania.
Mara: Is there a difference in non-suicidal self-injury between genders?
Dr. Flaherty: More females are reported to engage in NSSI, but that may be because male behavior looks different. Females do tend to cut more than males. A lot of times a boy will get angry and punch the wall repetitively. That might be minimized as ‘boys being boys’. But boys should not be punching a wall until their hands bleed, or they break their knuckles as a way to manage their emotions. That is not boys being boys.
Mara: Is non-suicidal self-injury different across cultural or racial groups?
Dr. Flaherty: Reports of NSSI are higher in Caucasian and white females, followed quickly by African-American and Hispanics, but very often kids in minority populations are not getting care, and so NSSI does not get reported. So, we don’t know if they’re doing it less or reported less. And self-injury is sometimes culturally appropriate. Think about tribal tattoos and the pain of joining the community. Is that self-harm? Other cultures that say any harm to the body, even a pierced ear is against their beliefs.
Mara: How much of non-suicidal self-injury is driven by social exposure?
Dr. Flaherty: If an adolescent self-harms, people in their circle are more likely to self-harm. That also goes for substance use and for sexual acting-out behaviors. They are most likely to engage in NSSI if they have pre-existing conditions, feeling upset or depressed. They are at a low point, feeling out of control, emotional: “I know this works for someone else. I’m going to try it.”
Dr. Feder: While individuals who engage in non-suicidal self-injurious behavior do not do so with the intention to die, continued behavior poses physical risks. For some, the self-harming behaviors will dissipate on their own, but for others it can increase in severity like other addictive behaviors. There is a theory that non-suicidal self-injury releases endogenous opioids, reducing pain sensitivity, which can result in more episodes and increased severity to feel relief from the behaviors. There is always a risk that the self-harm can result in infection or unintended death if the injuries are severe.
Dr. Flaherty, how do you assess for possible non-suicidal self-injury?
Dr. Flaherty: Ask about it. Some mental health providers worry that asking about NSSI will put the thought in the client’s head. That is completely wrong. They’re more likely to feel understood. It’s when you don’t ask the questions that they don’t feel safe talking to you. Asking screening questions is seven times more likely to discover NSSI as well as suicidal thought. Ask the questions in a caring way, and you’ve opened the door to say, ‘this is a safe place to talk.’ You’ll eventually get truthful answers, maybe not right away, maybe a week later. But you’ll get them.
Dr. Feder: How do you ask about non-suicidal self-injury in a way that helps patients feel comfortable talking about it?
Dr. Flaherty: Build up to it. Start with depressive symptoms, 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 I’ll normalize NSSI and ask: “When people are experiencing distress sometimes they’ll harm themselves. Have you ever done that?” I reassure them that this a safe place to talk about things.
Dr. Feder: How do you manage the child or teen’s concerns about confidentiality?
Dr. Flaherty: Do that at the very beginning. “What you say here stays here unless you’re harming yourself or others. If you’re harming yourself, I am going to tell your mom. I’m going to do whatever I can to keep you safe. It’s my job and I care about you. But let’s finish talking about what’s going on and then you and I can talk about if or what we’re going to tell your mom. We can talk about why you are worried about telling your mom and if she needs to know we can tell your mom together.
Mara: What do you ask next if they admit that they are engaging in self-harm?
Dr. Flaherty: You must sort out suicidal and non-suicidal intent and suicidal and non-suicidal behavior. If they confirm that they are engaging in NSSI, I’ll ask: “How are you self-harming?” Now is when you need to do a suicide assessment: “Have you thought about harming yourself so severely that you would end your life?” or “ Have you thought about ending your life?”
Mara: If we’ve determined that the child is not acutely suicidal, what do we do next?
Dr. Flaherty: Ask questions how and when they self-harm. It’s common to have ritualistic behavior, keep everything in a certain place, maybe turn on music and sit down in the same spot. This helps you understand how dangerous it actually is and also helps later with intervention. Impulsively taking a kitchen knife to their wrist is far different from using a safety pin on their leg. Then ask about how they feel before and after they self-harm. How often are they thinking about it during the day? Do they only think about it when they’re angry, sad, or are they constantly thinking about self-harming?
Mara: Dr. Flaherty, do you believe it is important to see the patient’s injury?
Dr. Flaherty: This question always comes up, and it’s even more complicated if you’re doing telehealth. If it’s in a location that they don’t have to remove clothing, I like to see it. You’re doing an assessment that includes whether this person is going to the ER. If they tell me they don’t cut so deep and it’s on their arm, and I see it and it’s deeper or looks infected, then they’re going to the ER. Not because they’re suicidal, but because that needs to be looked at.
Mara: When you are helping a patient talk to their parents, it is important to validate the teen’s concerns and use it as a therapeutic moment. You might 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, and how often they do it. You should prep the adolescent ahead of time so they know exactly what you will say.
Dr. Feder: When you talk with parents about non-suicidal self-injury make sure to use a soft calm tone of voice when speaking with them. For example you can approach the conversation saying something along the lines of: “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 unfortunately, 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 so that if parents become upset, we will allow a space for that, and the therapist will take the lead in the session.
Mara: Dr. Feder, how should clinicians approach the conversation regarding the disposal of sharp objects?
Dr. Feder: For someone who’s suicidal, you need to prioritize safety. Secure dangeous items such as knives and other sharp objects, medications, including over the counter meds like tylenol, motrin and aspirin, other poisonous household products, ropes and cords, and of course secure firearms, preferably out of the house and off the premises. Hospitalize the person if necessary. By contract, when someone’s non-suicidal, it’s good to 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 not only empowers the adolescent but also helps the parent understand the adolescent’s ritual and see things better from their teen’s perspective. This in turn can lead to better communication and problem solving as a team.
Mara: Do you recommend parents do body checks to look for injuries?
Dr. Feder: 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 it’s better to involve parents in a plan of what they can do instead if there is an urge to self-harm rather than checking for potential injuries.
Mara: Let's move forward and discuss treatment. Dr. Flaherty, what does treatment look like for non-suicidal self-injury?
Dr. Flaherty: With any high-risk behavior, we immediately do some harm-reduction techniques. The three most common for NSSI are the rubber band technique, the ice cube technique and tearing paper. We have them wear rubber bands around their wrist, ankle, etc. if that’s where they’re self-harming, and snap the rubber band instead of self-harming. We’d prefer that they didn’t have to feel pain in order to feel better, but this is a neither lethal nor dangerous. Holding an ice cube also feels painful but isn’t as dangerous as cutting or burning. Tearing paper can feel quite cathartic in the same way depending on what their self-harming behavior was.
Dr. Feder: It is important to note that all three methods are intended to reduce harm as we explore the root causes of the intense emotions through talk therapy. 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.
There are several talk therapies to address non-suicidal self-injury including Developmental Group Therapy (DGT), Mentalization Based Treatment for Adolescents (MBT-A), Dialectical Behavior Therapy for Adolescents (DBT-A), or 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. DGT is for kids 12–18 and includes behavioral, dialectical, social skills, and 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.
Mara: What about medications?
Dr. Feder: While there are no definitive medications for non-suicidal self-injury, there are small studies that suggest that medication is an option to treat co-occurring conditions such as depression, anxiety PTSD, BPD, and others in conjunction with psychotherapy.
Mara: Overall, the most important steps for supporting the treatment of kids and teens with non-suicidal self-injury, involve following an in-depth assessment and developing a treatment plan to reduce the non-suicidal self-injury behaviors and address the underlying causes.
Use a conversational approach when you talk about non-suicidal self-injury with a patient. But if you are looking for a semi-structured guide the book Treating Self-Injury has a review of formal assessments. Look over the assessments before the adolescent comes in, so you know what to cover.
Dr. Feder: Any final thoughts Dr. Flaherty?
Dr. Flaherty: Coming to therapy is the most impacting factor for changing this behavior as we can teach them different ways to manage it and appropriate coping mechanisms
Dr. Feder: Our upcoming printed interview with Dr. Flaherty will be available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry.
Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information you can trust.
Mara: As always, thanks for listening and have a great day!