Counseling Today, Cover Stories

When the hurt is aimed inward

Lynne Shallcross May 1, 2013

faceCutting. Burning. Headbanging. Embedding. Self-hitting. Pinpricking. Thinking about people intentionally hurting themselves in these ways can be difficult but, sometimes, counselors don’t have a choice.

When a client struggling with nonsuicidal self-injury (NSSI) appears in a counselor’s office, the counselor’s task is to help — and the perhaps natural reaction to cringe or admonish the client is not an effective way of achieving that goal, says Trevor Buser, an assistant professor of counseling at Rider University in New Jersey who has been researching and presenting on NSSI for about six years.

“A few of the NSSI methods, such as needle insertion, are a bit graphic to describe,” says Buser, who presented on assessing and diagnosing NSSI at the American Counseling Association 2013 Conference & Expo in Cincinnati in March. “I sometimes notice students grimacing when I deliver a lecture on the topic. This kind of reaction is understandable. I’ve felt unsettled too upon hearing some descriptions of NSSI. At the same time, we need to be sensitive to the verbal and nonverbal communications that we are sending to clients about these behaviors. Several authors have recommended that we counselors maintain a calm, accepting posture while clients share details about the use of NSSI.”

Offering that sense of calm and acceptance was integral to Kim Johancen-Walt’s work with “Jennifer,” a client Johancen-Walt calls one of her most memorable. When Johancen-Walt first met Jennifer, then 15, the teenage client was already cutting several times daily, but that soon ballooned to upward of 50 times a day. During the course of their work together, Jennifer was placed in residential treatment and was hospitalized once due to life-threatening circumstances from her self-injury.

Jennifer experienced trauma as a child, having grown up in a chaotic environment with an absent father and an alcoholic mother. “Although Jennifer’s family had overcome many challenges and now offered support, she was still struggling with old patterns of thinking that continued to fuel self-injury,” says Johancen-Walt, an ACA member who has 20 years of experience working with clients on issues of self-injury and suicide in a variety of settings. A third of her caseload in her private practice in Durango, Colo., involves clients either currently or formerly engaged in self-injury. “When I asked Jennifer why she self-injured, she talked about how it helped her to ‘feel something.’ Due to her childhood experiences, she had a deeply infected belief system that she was both invisible and undeserving.”

Equipped with that information and knowing that Jennifer felt very disconnected from herself and others, Johancen-Walt focused on building her relationship with Jennifer. “I wanted to give her a corrective experience in our therapy that communicated that she was both seen and valued. I accepted her unconditionally and told her she deserved love and kindness throughout treatment,” Johancen-Walt says. “Although the old messages of self-hatred were still there, she now had a different way of defining herself. With my help, along with [that of] many others, she was eventually able to do what I now refer to as ‘putting a wedge in the choke hold of self-injury.’”

Johancen-Walt still has a list that Jennifer found online of 72 strategies to avoid self-mutilating. The strategies include putting a rubber band on your wrist and snapping it when experiencing an urge to self-harm and holding ice cubes until they melt. But Jennifer’s favorite strategy was one that she created herself — going someplace where self-injury was not invited and committing to stay there until the urge passed.

“She reminded me that just as with other types of addictive behavior, we have to help people replace faulty coping skills with more effective ones,” Johancen-Walt says. “This takes time, but eventually the scale can tip and the costs of self-injury can begin to outweigh the benefits [for clients]. She also taught me how quickly habituation can happen and why we have to talk about self-injury from the beginning of treatment.”

At the point when Johancen-Walt and Jennifer stopped working together, Jennifer was still having occasional “slips,” Johancen-Walt says, but she was also righting herself more quickly and maintaining the progress they had made together. “We both defined her treatment as a success and acknowledged that she was a long way away from where she was at the beginning of treatment,” Johancen-Walt says.

Johancen-Walt emphasizes that she represented only one component of the support Jennifer received. Her support system also included her family, the caregivers in residential treatment and the school-based outpatient program where Johancen-Walt was then working as a therapist. “I believe that our work — and relentless support — helped her explore other possible ways of viewing herself in the world and an awareness that reality is subjective,” Johancen-Walt says. “Although it took several months, and a break from therapy while in residential treatment, she was finally able to accept care and validation from others, and [she] improved quickly. Her lens had effectively changed,” says Johancen-Walt, who contributed a chapter to The Adolescent & Young Adult Self-Harming Treatment Manual by Matthew D. Selekman.

Jennifer stands as one of the most difficult self-injury cases Johancen-Walt has ever treated, and yet she also remains a lasting inspiration to Johancen-Walt. “Jennifer is probably one of my most memorable cases not only because I saw her early in my career as a therapist, but for a variety of other reasons as well. She taught me more about self-injury than any book or course could have ever offered, and she also taught me about the resiliency of the human spirit. Jennifer eventually stood up to self-injury and suicide and offered me countless tips and strategies that I still use to this day. When I am feeling discouraged about a particularly difficult case of self-injury, I think of her and remember that there is always hope. I carry that with me on the journey.”

An equal-opportunity issue

Reported rates of self-injury vary, depending in part on the definition researchers use for self-injury and the population being studied, says Victoria Kress, a professor of counseling at Youngstown State University in Youngstown, Ohio. The highest rates are typically reported among adolescents. An article published last year in the journal Pediatrics notes that in samples of early adolescents and older adolescents, the rates of NSSI range between approximately 7 and 24 percent.

Together with researchers from Stanford, Harvard, Cornell and Princeton, Kress studied self-injury among college students from eight universities in 2006 and 2007 and found that the lifetime self-injury rates among that population averaged a little more than 15 percent.

Although there is a higher prevalence for self-injury among adolescents and college-age young adults, Kelly Wester, an associate professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, points out that NSSI has been reported in children as young as 7 and in adults older than 70. It is not uncommon for self-injury to begin during adolescence and continue into adulthood, according to Wester.

“The longer someone engages, the harder it is to extinguish it,” says Wester, an ACA member who presented on self-injury at the ACA Conference in Cincinnati. The longer self-injury continues, she explains, the more likely it will become an automatic response in how the person copes with stressful events, emotions or thoughts. Over time, clients might come to view self-injury as something that has “always worked for them,” Wester says.

NSSI refers to the deliberate, direct, self-inflicted damaging of a superficial or moderate amount of bodily tissue without the intent to die and without social sanction, says Buser, past president of the International Association of Addictions and Offender Counselors, a division of ACA. “The issue of social sanction is emphasized … to differentiate this behavior from culturally accepted forms of self-injury, such as body piercings or rites of passage,” he adds.

Several recent studies have found no variation in rates of NSSI according to racial or ethnic background, biological sex or socioeconomic status, Buser says. However, higher prevalence rates have been identified for individuals who identify as lesbian, gay or bisexual, he says.

Historically, self-injury has been conceptualized primarily as a problem among females, but research shows that it is just as common among men, says Kress, president of Chi Sigma Iota, the international counseling honor society, and a presenter at the ACA Conference on spirituality as an insulating factor against NSSI. There are gender differences, however, in how people self-injure, Kress says. For instance, men are more likely to engage in self-hitting and head-banging, whereas women are more likely to engage in cutting.

Buser says one of the best known models, developed by Matthew Nock and Mitchell Prinstein, organizes the functions of NSSI into four basic categories, two involving interpersonal functions and two involving intrapersonal functions. “From the interpersonal perspective, clients may use NSSI as a way to avoid negative exchanges with others — for example, punishment — or obtain positive exchanges with others — for example, concern or care,” Buser says. “From the intrapersonal perspective, clients may engage in NSSI to stimulate positive affect or to reduce negative affect. In reviews of research on this topic, it appears that affect regulation — for example, tension reduction — is the most commonly reported function by clients who self-injure. In this sense, NSSI can be conceptualized as a coping mechanism for many clients.”

Indeed, Wester says a common thread among clients who self-injure is difficulty with emotional regulation. Oftentimes, these clients either don’t understand the emotions they are feeling or are unable to communicate them, so when something stressful happens, they can’t regulate their emotional state and can’t tolerate the feelings. Self-injury temporarily allows these individuals to relieve the emotional pain or connect with it, Wester says.

The goal for counselors, Wester says, is to help these clients recognize they are gaining control only temporarily through self-injury. With a counselor’s help, she says, clients can learn to slow down, identify the emotion, label it correctly and deal with it, thus gaining more permanent control without resorting to self-injury. Once clients possess the ability to regulate those heightened emotions, they are less likely to move forward into self-injury, Wester says.

On another end of the spectrum, Wester says, people who feel emotionally numb may self-injure in an effort to feel something. Additionally, Johancen-Walt says, although anyone can be at risk for self-injury, unresolved grief and loss appear to be common risk factors.

An invitation to share

Whether a client will present in a counselor’s office and openly acknowledge engaging in self-injury depends on the individual, Buser says. “Certainly, some clients are ashamed about their use of NSSI and may not disclose it to a counselor,” he says. “In fact, there is evidence that most individuals who perform NSSI do not seek psychotherapeutic services at all.”

Johancen-Walt says that many of her clients who self-injure are referred by others who care about them, including family members, friends, other counselors, teachers or doctors. “Out of those self-referred, many have reached a state of desperation where they feel completely out of control because either the self-injury is no longer working for them or because they know they are becoming more at risk,” she says.

In Wester’s experience, many clients who self-injure present with other issues such as depression, anxiety or grief. Because clients might feel uncomfortable mentioning that they self-injure, Wester says counselors should include questions about self-injury in their intake paperwork, in addition to asking the question directly in session. “Verbally ask if the client has hurt themselves in any way intentionally,” she says. “Ask for examples, and tell the client you know it’s different from suicide. It tells them that the counselor is OK with talking about it.”

Johancen-Walt agrees. “Clients are checking out our comfort level with this topic from the moment they enter our offices,” she says. “If I fail to address it, then I risk communicating to my client that I am not safe. If I can’t tolerate holding self-injury, then I can’t tolerate the reasons they are doing it.”

Additionally, if a client relays information about a significant loss, Johancen-Walt typically asks how the client has been coping with the impact of that loss. “This question is an invitation to talk about self-injury if it is in the room,” she says. “[With clients who] have not disclosed self-injury but I suspect it has been one of their strategies, I may offer stories of others who have experienced similar losses to those of the client and who resorted to various forms of self-injury. I will then ask the client if this is something they have thought about. This invitation communicates to the client that they are not alone and also communicates that I have experience talking to clients about it.”

Kress has worked for nearly two decades with clients who self-injure and has been researching and writing about the topic for 15 years. She offers a number of questions that can be helpful in assessing a client’s self-injury behavior and identifying potential risks:

  • Have you ever deliberately cut your body, burned your body, stuck sharp objects into your arm, broken your own bones, banged your head against a wall or picked at scabs or injuries without intending to kill yourself?
  • If yes, describe when you first did this, when you most recently did this and how often you do this.
  • Was there a time in your life when you engaged in self-injury more frequently? If yes, when?
  • Was there ever a time that you felt like you didn’t need to self-injure? If yes, what was different at that time?
  • What does self-injury mean to you?
  • What are some of the reasons you self-injure?
  • Do you wish to stop self-injuring?

Johancen-Walt and Wester point out that clients who engage in self-injury often use more than one method. Over time, Wester says, the severity of the chosen method of self-injury can increase.

Buser and his wife, Juleen Buser, who is also an assistant professor at Rider University, developed the HIRE model last year to assess a client’s self-injury behaviors. HIRE stands for history, interest in change, reasons for engaging and exposure to risk. The model helps counselors facilitate an informal assessment of NSSI in those four primary domains.

In the HIRE model, “history” refers to clients’ methods and frequency of engaging in NSSI. “Interest in change” refers to their motivation for reducing NSSI behaviors. “Reasons for engaging” provides counselors with insights into what clients are trying to alleviate. “Exposure to risk” addresses safety concerns, such as sense of control while self-injuring, use of alcohol or drugs while self-injuring and level of tolerance to self-injury.

More information on the HIRE model will be included in an article the Busers wrote that is in press for an upcoming issue of the Journal of Mental Health Counseling.

Finding a way in 

After identifying that a client is engaged in self-injury, Buser recommends conducting a functional analysis of the behavior as a good first step. Determine how, when and where the client is engaging in self-injury. From the client’s perspective, what purposes does it serve? How does the client feel during and after the self-injury?

“In the midst of these questions, I’ve found it useful to remember the value of empathy and other Rogerian conditions such as positive regard,” Buser says. “Many clients have gone to great lengths to hide their use of NSSI from others. Ideally, then, we’re attempting to provide a place where clients can share openly about NSSI and reflect on the functions being served.”

Another important preliminary step is bringing attention to safety concerns, Buser says. “If, for example, the client regularly uses alcohol or drugs or dissociates while self-injuring, then more intensive levels of intervention might be advisable,” he says. “Although we can point to indicators of increased risk for harm, as described in the NSSI research, I believe it’s particularly important for counseling staff members to come together and establish protocols for handling extreme cases of NSSI within their setting.”

Although most people don’t see any appeal to self-injury, it is important to understand that those who engage in it do so because they are getting something out of it, says Kress, who directs a community counseling clinic at Youngstown State. “You can’t say, ‘OK, you can’t do this anymore,’ and [expect that] will just happen,” she says. “If it was that easy, we [counselors] wouldn’t have jobs.”

Kress works with clients to highlight the natural consequences of self-injury and determine what problems the behavior might be causing in their lives. She says enhancing these clients’ motivation to change is paramount because, otherwise, they may choose not to follow through on what the counselor suggests.

In fact, after first assessing clients’ self-injurious behavior, Kress says the second step counselors should take is to assess clients’ motivation to stop. Kress finds motivational interviewing questions helpful for that purpose. Among the questions she uses:

  • How is self-injury getting in the way of you reaching your life goals?
  • How is the self-injury getting in the way of your day-to-day life?
  • What negative consequences has the self-injury invited into your life?
  • What is important to you? How does the self-injury get in the way of these important things?
  • What would your life look like if self-injury were not in it?

“Many people assume that clients who self-injure want to stop the behavior,” Kress says. “In my experience, almost all of my clients have ambivalence about ceasing the self-injury. A part of them finds that this behavior is working for them. The interventions typically used with this population, such as cognitive behavior therapy (CBT) or behavior therapy (BT), require [that] the client is motivated to change. If the client isn’t motivated to change, attempts to use CBT and BT approaches will likely be unsuccessful since in these approaches, clients are required to be active participants. In assessing and then enhancing a client’s motivation to change, counselors can develop a better understanding of the client’s motivations and goals, build trust via this collaborative process and deepen a client’s motivation to follow through on making behavioral changes. Even with clients who have no interest in ceasing the self-injury, I find that over time and with increased trust, I am able to assess the negative impacts and consequences of the self-injury and use that as a building block upon which behavioral changes can then be invited.”

One of the most important ingredients in a counselor’s ability to effectively help NSSI clients is building a strong therapeutic alliance, Kress says, and that includes not forcing the counselor’s values or goals on the client. In the opinion of Kress, if clients aren’t self-injuring with suicidal intentions, it is not appropriate for counselors to tell them they must stop.

Wester agrees, saying it is up to the client, not the counselor, to determine that extinguishing the self-injurious behavior should be the goal. Wester sets boundaries and communicates those boundaries to clients, telling them she will report their self-injurious behavior if there is mortal danger or if the individual is suicidal. But outside of that, she doesn’t force clients to set a goal of eliminating the behavior.

“You’re not going to make a client do something they don’t want to do,” she says. “If they’re open and honest with you, you need to accept them for what they’re doing and who they are. Be genuine and offer unconditional positive regard. What I’ve found in the past is if you force [the behavior to stop], clients will continue to do it; they just won’t talk to you about it, so it can actually become more dangerous.”

Probing the question of why these clients self-injure is also crucial, Johancen-Walt says. “People self-mutilate for a variety of reasons, and we have to be careful about making assumptions about a behavior. Over the years, I have received countless answers to that question. However, one of the most common responses I have received is that it serves as a form of ‘relief’ from emotional suffering. In these instances, it can be both a distraction and expression of emotional pain.”

Another common explanation is that clients want to “feel something,” Johancen-Walt says, which is usually indicative of those who feel incredibly disconnected from themselves and from those around them. Although less common, Johancen-Walt says some clients use self-injury as a form of self-punishment. “They have come to believe that they have to be punished, not only for their mistakes, but also for the mistakes of those around them,” she says.

Counselors must be careful not to make assumptions about these clients, especially concerning whether they are “attention seeking” or “manipulative,” Johancen-Walt says. “If a therapist communicates a kind of blasé attitude toward a client’s self-injury, then they are at risk of communicating to the client that their wounds are not significant enough to warrant care or even attention. Through this type of interaction, we are telling the client that they need to do something more drastic or life-threatening to get our help and support.”

Treatment and the therapeutic relationship

In reading the research being done in this area, Buser says it is too early to determine which counseling treatment is most effective for NSSI. He agrees with Kress’ suggestion of motivational interviewing, pointing out that it originated in treating addictions but has been used more recently with self-injury as well. Several researchers who have written on the topic have discussed the use of CBT in treating these clients, Buser adds. This would include finding and rehearsing replacement behaviors that may satisfy the same functions clients are seeking with self-injury but in a more adaptive way.

Kress notes that research has also supported the use of dialectical behavior therapy (DBT). “An example of a behavioral therapy technique, which is also used in DBT and often in CBT approaches, is a chain analysis,” Kress says. “In a chain analysis, you break down the sequence of behaviors and events — one at a time, like a chain — that lead to an incident of self-injury. A chain analysis is kind of like a road map in which the clients identify how they arrived at the place of self-injury. They identify where the road began and possible alternative adaptive pathways that lead away from the self-injury. In developing a chain analysis, clients can develop insight into their self-injury triggers, as well as the thoughts and their actions that have supported self-injury, and they can learn how to respond in more adaptive, self-nurturing ways.”

Working from a strengths-based perspective allows these clients to find and lean on their own existing strengths for support, Kress says. “For example, one of my clients is a voracious reader and found that reading helped distract her from stressful situations. We developed a behavioral plan that involved her always carrying a book in her purse, and she would read when she had urges to self-injure. Pulling on clients’ identified resources is so much more powerful than a counselor suggesting behavioral distractions. Clients know best what works for them. As a counselor, I see my role as being the person who supports them in identifying and applying their strengths.”

In a study Wester conducted, therapy from any perspective was shown to be helpful to clients dealing with self-injury. “I think it goes back to the therapeutic relationship,” Wester says. “It’s the nonjudgmental aspect.” Wester says she consistently hears from these clients that they feel judged, whether by medical professionals, teachers or others, for their self-injurious behavior. As a result, the individuals feel shamed and hide their behavior further. Regardless of the counseling theory or technique followed, Wester says, the most helpful thing a counselor can bring to session with a self-injuring client is unconditional support and nonjudgmental acceptance.

Johancen-Walt says she also tries to help clients externalize the self-injury. “I will teach clients who are ashamed and not wanting to talk about their behavior or what is fueling it that self-injury wants them to stay silent,” she says. “Self-injury keeps its power by being the only ‘person’ the client can confide in. It doesn’t want the client talking about it because it would feel threatened. Many clients feel isolated and separated from caring others, and I remind them that self-injury wants them alone so that it can remain a central figure in their lives.”

“In order to stay vigilant early in recovery,” she continues, “I remind clients that self-injury is a tricky beast, and if we extinguish one form of self-injury, then it may try to find another way in. It will have a new face but will still be trying to exert its power over the client. For example, a client who no longer experiences relief from cutting may begin flirting with other forms of self-injury, such as eating-disordered behavior, unaware that self-injury found a side door.”

Externalizing the behavior can also reduce resistance on the part of the client, Johancen-Walt says, helping the counselor and client to form a united front against self-injury.

With clients whose self-injury stems from an inability to identify emotions, Wester says creative approaches such as the expressive arts or music can sometimes help more than talk therapy alone. Wester has used masks with clients who self-injure, inviting them to draw or write on the outside of the mask what they show to the outside world. On the inside of the mask, they write or draw what they are experiencing internally. Wester often uses music with adolescent clients, asking them to bring in songs that represent what is going on in their lives.

Self-injury and suicide

Research suggests that counselors view working with self-injuring clients as one of the most stressful aspects of being a counselor, Kress says, in part because they worry about these clients attempting suicide. Kress points out that, by definition, self-injury is different from suicide. “It’s causing damage without suicidal intention,” she says.

Wester concurs, explaining that self-injury and suicide serve very different purposes for clients. “Suicide is to end life,” she says. “Self-injury is to control something in order to keep living and move forward.” In fact, Wester says, self-injury can even be a suicide preventer for some clients, providing them with what they view as temporary relief from suffering.

However, Kress says, she and some of her counseling colleagues conducted research in the fall and found that self-injury can sometimes be a gateway to suicide attempts. The research was published in the Journal of Adolescent Health in April and involved 1,466 students at five U.S. colleges. “If someone self-injures, you do want to take that seriously because they do have a higher risk for suicide attempts,” Kress says.

Buser says researchers have found that individuals who engage in NSSI are more likely to experience suicidal thoughts, and Johancen-Walt adds that suicide risk increases the longer someone engages in self-injury.

As difficult as it is to absorb that information without feeling anxious, Kress implores counselors not to overreact, such as by attempting to hospitalize clients to make them stop injuring themselves. “We have an ethical obligation to intervene if they’re suicidal, but with self-injury, if they don’t have suicidal ideation, you can’t [force them to stop],” she says.

If a counselor tries to force a self-injuring client to stop when the client hasn’t set that as a goal, it can harm the therapeutic alliance, Kress says. However, she says, counselors can and should regularly assess self-injuring clients for suicide risk.

Buser points out that suicide assessment questions should directly inquire whether a client is having thoughts about killing himself or herself because vague questions about “hurting” oneself could lead to confusion.

Johancen-Walt emphasizes that counselors should not assume that clients engaged in self-injury are suicidal because many are not. “However,” she says, “if self-injury is not addressed in treatment, a client’s risk of suicide may increase over time. This happens as tolerance to the behavior increases. These individuals may need ‘more of the drug’ in order to achieve the same amount of relief from their earlier behavior. For someone who is cutting in order to cope with emotional pain, this is a dangerous addiction. If these behaviors are left unchecked, a few shallow cuts to the wrist could change into deeper injuries resulting in permanent injury or death.”

A little understanding

In terms of fully understanding self-injury, Wester says, there is still a long way to go. For example, she says, the biological roots of self-injury and the reason people choose self-injury are still unknown. “There are a lot of theories and models that explain self-injury once clients are engaging in it, but there is little known about why people choose it. Why not eating disorders or substance abuse [instead]? No one truly understands why someone chooses self-injury over something else.”

The biological components of self-injury are just beginning to show up in research studies, she adds, but the question of why people choose self-injury over a different maladaptive coping mechanism has yet to be tackled.

Research will likely inform where treatment for NSSI goes in the future, but these counselors offer a few pieces of current guidance to those working with clients who self-injure.

Remember that the end goal may not be to eliminate the self-injurious behavior completely, Johancen-Walt says. Instead, it may be to change the client’s relationship with the behavior. “For example,” she says, “when the client is triggered and experiences an urge to ‘use,’ they can view that event as an opportunity to practice more effective coping skills, to figure out what they need and to validate themselves. This is a process I refer to as ‘shaking hands’ with self-injury.”

Johancen-Walt says counselors must also understand that these clients are engaging in self-injury in an attempt to survive; otherwise, they wouldn’t be doing it. She encourages counselors to share that sense of understanding with their clients. “I have had several clients over the years tell me that if they had not been self-mutilating they would have completed suicide,” she says. “By sharing this [understanding] with clients, I am not only communicating unconditional acceptance, I am also saying something to them that they have not heard from others in their lives, who have typically reacted out of fear and panic.”

Kress echoes that need for understanding. “Understand that the self-injury is their attempt to regulate their emotions. In a way, it is a life-sustaining behavior, whereas suicide is a life-taking behavior,” she says. “Consider what the client is trying to convey to themselves or to others by injuring. [This] is where you will find their ‘soft spot’ and be able to help them heal and change. People who self-injure have many capacities. Help them connect with these strengths and help them use these strengths to fight the self-injury influence.”

Finding the “soft spot” within each client means recognizing that each individual is unique — something Johancen-Walt says is vital in this work. One of her mentors taught her that counselors get into trouble as soon as they think they have clients figured out. Johancen-Walt carries that lesson with her, especially in her work with self-injuring clients.

“This is an important reminder for therapists who may think they have ‘seen it all,’” she says. “I remember that clients coming to my office are all unique individuals with their own unique set of challenges, strengths and resources. It is my job to listen.”

To contact the individuals interviewed for this article, email:

Prevention efforts

Not much is known about how to prevent self-injury among clients who have not yet begun to engage in it, says Victoria Kress, a professor of counseling at Youngstown State University in Ohio. But considering that self-injury often relates to an inability to regulate emotions, she believes any techniques that involve enhancing emotional regulation, identifying emotions and expressing feelings would be helpful in averting future self-injurious behavior among clients.

“Since interpersonal interactions and frustrations are the incidents that most frequently spur an episode of self-injury, people may benefit too from social-skills training, which places an emphasis on enhancing one’s ability to effectively communicate with others, especially as related to conflict situations,” Kress says. Additionally, research Kress recently completed suggests that helping to enhance a client’s sense of spirituality, meaning in life and life purpose may help to prevent self-injurious behaviors.

Prevention efforts would do well to focus on the development of basic coping and social skills, says Trevor Buser, an assistant professor of counseling at Rider University in New Jersey. “For example, training in stress management techniques, such as mindfulness, diaphragmatic breathing or progressive muscle relaxation, may provide healthy alternatives for individuals who would otherwise perform NSSI [nonsuicidal self-injury] for emotional regulation,” he says. “Incidentally, the same approach is often taken in prevention programs for substance and alcohol abuse, so these types of programs may be protective in multiple ways.”

— Lynne Shallcross

Learn more

For additional reading on the topic of self-injury, consider checking out these journal articles published by ACA or its divisions:

  • “Exploring Self-Injury Through a Relational Cultural Lens” by Heather Trepal, Journal of Counseling & Development, Fall 2010 issue
  • “Coping Behaviors, Abuse History and Counseling: Differentiating College Students Who Self-Injure” by Kelly Wester & Heather Trepal, Journal of College Counseling, Fall 2010 issue
  • “Assessment and Self-Injury: Implications for Counselors” by Laurie Craigen, Amanda Healey, Cynthia Walley, Rebekah Byrd & Jennifer Schuster, 
  • Measurement and Evaluation in Counseling and Development, April 2010
  • “Self-Injurious Behaviors: Assessment and Diagnosis” by Victoria Kress, Journal of Counseling & Development, Fall 2003 issue

Lynne Shallcross is the associate editor and senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org

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3 Comments

  1. Kay Trottter

    Thank your for this very timely article, as my office will be talking about this very same issue at an Parenting University put on my the local school district. I plan on sharing this not only with the participants but this other also.

    Thanks again Kay Trotter.

    Reply
  2. Ginger Ale

    The most important aspect missing here (unless I missed it) that shouldn’t ignored is the actual biological response in the body that occurs when someone is injured. Regardless of whether or not it’s self injury, all kinds of feel good, pain relieving endorphins/hormones are released when someone is injured. It’s providing everything from an actual high due from epinephrine and actual physical pain relief. pain relief, a boost of energy (epinephrine) and an overall feel good response from the biological response that kicks in when the body is harmed.

    Cutters and self mutilators get a high from it.

    I think psychology would be better served by actually employing science behind them and the lack thereof in this article makes me sorely disappointed in the authors. They clearly haven’t done their homework.

    “There are a lot of theories and models that explain self-injury once clients are engaging in it, but there is little known about why people choose it. Why not eating disorders or substance abuse [instead]? No one truly understands why someone chooses self-injury over something else.”

    Absolutely untrue. It’s also documented that the act of vomiting also releases feel good hormones. Bulimics have been known to admit they get a high off of purging.

    Do your homework!! Look at the science. Look at the biological responses and stop focusing on nothing more than the surface of these problems.

    Reply
    1. self injurer

      I think people are wrong about the endorphins if that was the case then everyone would do it and nobody would stop or want to. When I got hair in my mom said I would pull it out was ashamed of permanent bald spot made on my head otherwise would not have mattered but that would have made me less then year old. I was hitting my head against walls enough to break the plaster by time I was 4 or 5, was sticking pins in my arm by second grade (teacher sent me to nurse) and went on from there I am now over 50 when upset still pull hair and bang head on walls and cut or burn or combination to calm myself down. I also use food. Counselors say is coping for me and nobody will even really discuss how to stop I have tons of avoidance things to do first but still not enough. I have never been able to identify feelings. I have never gotten high need the pain to make other pain go away. I have also always felt the pain while doing it but at least is more manageable.

      I think the article is right I have never had anyone to talk to about it if do they want you to stop now and I can’t. I don’t know how they proved the science have heard that before but just not logical or why doesn’t everyone do if that simple to get high. I know of nobody that would like to continue doing it if could stop.

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