The prevalence of nonsuicidal self-injury (NSSI) among adolescents and young adults has rapidly and significantly increased in recent years, leading mental health professionals and researchers to describe its pervasiveness as epidemic. By definition, a person does not engage in NSSI with intent to die. Rather, NSSI is a means of regulating emotions, relieving tensions, managing dissociative symptoms and influencing others. It is critical that counselors working with youth gain an understanding of NSSI and recognize its prevalence within the adolescent population.
There is growing evidence that many teenagers who engage in NSSI have been influenced by their peers. In 1985, Barent Walsh and Paul Rosen defined self-injury contagion in two ways:
1) When acts of self-injury occur among two or more persons within the same group within a 24-hour period
2) When acts of self-injury occur within a group of statistically significant clusters or bursts
The primary focus of this article is to identify environments that present a high risk for self-injury contagion and to suggest opportunities for counselors to minimize and prevent contagion when working with adolescents.
Benefits and pitfalls of group work
Many programs designed to treat adolescents who self-injure include group therapy as an essential ingredient in the treatment milieu. S.A.F.E. (Self Abuse Finally Ends) Alternatives, founded in 1985 by Karen Conterio and Wendy Lader, was the first treatment facility designed specifically for people who self-injure. Since its inception, clinicians at S.A.F.E. Alternatives have used group therapy as a central feature of its treatment programs. Dialectical behavior therapy (DBT), which combines individual therapy, group skills training and family education, has emerged as one of the most effective treatments for adolescents who are suicidal and/or self-injure. Many of the key skills needed to reduce self-injurious behaviors (for example, emotional regulation, distress tolerance and interpersonal communication skills) are learned and practiced in group therapy. Solution-focused therapist Matthew Selekman recently developed a nine-session Stress-Busters’ Leadership Group geared specifically toward adolescents who engage in self-destructive behaviors. The group is applicable in both school and community settings. While these group approaches (S.A.F.E. Alternatives, DBT and Stress-Busters) have several differences, it is important to note that each is largely didactic, highly structured and skill-based.
Group work is appealing both to adolescents and counselors for a number of reasons. For logistical and developmental reasons, group homes, residential facilities and hospitals typically utilize various forms of group work as their primary mode of treatment. Groups are more efficient and cost-effective than individual approaches because they enable counselors to work with more clients. In addition, group work tends to be a better developmental fit for adolescents than individual therapy, and adolescents often prefer it because a significant amount of social learning occurs in the context of formal and informal groups (for example, family group, classroom group, social group and sports teams).
Youth who self-injure tend to feel isolated and disconnected. Although individual counselors can inform youth that they are not alone, the group process allows them to experience a sense of universality with their peers, while learning from others who are at different stages in the recovery process. By assisting and supporting others, members begin to see themselves in a different light. One of the most effective ways to boost a youth’s self-esteem and self-confidence is to structure situations in which he or she can help others and feel altruistic.
Despite the potential benefits of using groups as a component in treating those who self-injure, there are also possible pitfalls that could disrupt the process or even increase self-injurious behaviors. Walsh, author of Treating Self-Injury, says counselors should be mindful that anytime individuals who self-injure are treated in groups, there is an increased risk for a contagion effect. In addition, he warns that groups that are largely cathartic in nature — wherein youth are encouraged to openly express their emotions and share traumatic experiences — are often counterproductive with this population. These types of groups can increase the risk of contagion because open discussion of self-injury antecedents, behaviors and consequences can be exceptionally triggering for some young clients.
Many clinicians and researchers assert that group leaders should structure activities that focus on empowerment and replacement or coping skills training, while prohibiting detailed discussion of self-injury. This can be challenging for counselors because sharing and hearing details about self-injury can be so alluring for both counselors and group members. Adolescent clients may view group therapy as an opportunity to compare wounds and share stories. These disclosures should be severely limited or prohibited from the onset, however. Counselors may want to acknowledge that discussing self-injury in great detail may be important but emphasize that those details should be shared in individual therapy rather than with group members.
In summary, NSSI groups are most likely to be effective if:
1) Group leaders have significant training and understanding of treating self-injury and managing contagion
2) Membership is closed to enhance cohesion and trust
3) The group is governed by strict rules prohibiting the discussion of details of self-injury and the sharing of wounds or scars in the group
4) As with DBT groups, the sessions are highly structured, didactic and focus on teaching new skills and behaviors (for example, emotional regulation, mindfulness, self-soothing, distress tolerance and exercise) to help reduce further incidents of self-injury
Benefits and pitfalls of residential facilities
Similar to treatment in group therapy, clinicians who work with youth in residential treatment can be effective in counteracting self-injury, provided they follow the proper precautions.
The residential population is likely at higher risk for contagion due to peer influence and the prevalence of severe psychopathology such as eating disorders and issues with affective regulation. In fact, a number of researchers have observed that NSSI occurs in significant clusters in residential settings, including community-based group homes, special education boarding schools, juvenile detention facilities and psychiatric inpatient settings. Recognizing the potential for contagion in a residential population allows for appropriate precautions when determining the benefits of residential treatment on a case-by-case basis, and it can aid in the appropriate response to NSSI.
Several studies have found that self-injurious behaviors often increase for adolescents, regardless of whether they have a prior history of self-harm, during residential treatment. Clinical settings that feature multiple youth living together who exhibit emotional dysregulation can aggravate dysfunctional behaviors, including NSSI. Consequently, the increased likelihood of exposure to self-injury in a residential facility leads to the question of whether the benefits of inpatient care are worth the potential risks associated with contagion.
Despite concern for social contagion, several arguments can be made in favor of choosing residential treatment for NSSI. For example, cases that include high-risk behaviors such as clinically significant disordered eating require structured, intensive treatment. In similar circumstances, placement in a residential facility may be warranted, even if nonresidential treatment may pose less risk of self-injury contagion.
The first step in response to the risk of social contagion is making the appropriate referral to residential care on an individual client basis, while avoiding unnecessary hospitalization. Within the residential setting, precautions guide clinicians toward the appropriate response to NSSI. These responses include educating the individual client, confronting triggers of social contagion and using encouragement to motivate youth to build and share healthy coping skills.
Subsequently, many of the challenges and recommendations for counselors who work in residential facilities are similar to those provided for group counselors. Although communicating with peers in a communal environment is beneficial for those who feel isolated and may benefit from peer support, mental health counselors are advised to educate residents on the negative effects of sharing stories of self-injury. These clients should instead be instructed to share stories of healing and healthy coping behaviors.
Benefits and pitfalls of websites and message boards
Although the Internet is a potentially valuable source of support and information for self-injurers, various websites can also be breeding grounds for social contagion. Approximately 93 percent of American youth ages 12 to 17 use the Internet, and nearly two-thirds of adolescent Internet users go online daily. These numbers are growing every day. In the past decade, the number of websites intended for or about people who self-injure has increased. Research conducted in 2007 by Janis Whitlock, Wendy Lader and Karen Conterio revealed there were more than 500 message boards focused on self-injury. These researchers also observed the parallel between the increase in self-injury websites and the growth in self-injury awareness in society. Internet message boards provide a potent medium for bringing together adolescents who self-injure.
These self-injury websites and message boards offer a number of potential benefits. The Internet may have particular relevance and appeal for adolescents who are socially avoidant or feel marginalized. These youth may feel extreme relief upon finally being able to make meaningful connections with individuals who share similar concerns and experiences. The anonymity of these sites might also encourage youths to share more frequent and truthful disclosures about their feelings and behaviors. Positive peer pressure is another potential benefit. As is the case in group counseling, these adolescents might more readily accept online feedback from peers that encourages them to practice safer, more productive ways of expressing their emotions.
Thus, it is important that counselors not minimize the perceived value that these sites have for young clients who self-injure. Though social scientists and mental health professionals often focus on the potential harm of these discussion groups, adolescents who use them tend to self-report positive experiences as a result of their participation. For example, in one survey of self-harm discussion group members, Craig Murray and Jezz Fox found that the majority of respondents reported having reduced the frequency and severity of their self-injurious behaviors. The respondents attributed this largely to the support and guidance they found online.
Whitlock and her colleagues were some of the first researchers to study the content of self-injury message boards to better understand their role in sharing information about self-injurious practices and influencing help-seeking behaviors. These researchers found that the most common type of exchange on the message boards involved providing informal support to other posters through comments such as “We’re glad you’ve come here” and “Just relax and try to breathe deeply and slowly.”
However, in addition to the supportive communication found on NSSI-related sites, researchers also found dangerous messages. While 44 percent of all help-seeking posts presented favorable attitudes toward seeking mental health treatment, approximately 20 percent of the posts discouraged individuals from seeking treatment and/or voiced negative views about therapy. There was also considerable discussion about better ways to conceal scars and maintain secrecy.
These researchers warned that self-injury message boards expose vulnerable youth to a normalizing environment of encouragement for self-injury and hold the potential for fueling social contagion. On several sites, members shared new and often more dangerous techniques and instruments for cutting and even offered links to sites where self-injury paraphernalia could be purchased. Sites that feature graphic depictions of self-injury, including many videos on YouTube, can be highly suggestive or triggering to other self-injurious participants. Unfortunately, those who self-injure can become better at self-injury by learning from others they meet online. Some posters use chat rooms to coerce others, model self-destructive behaviors, compete with others and discourage others from stopping their self-injurious behaviors or seeking help.
As is evident, self-injury websites and message boards are helpful for some and counterproductive for others. Regardless, this needs to be an area of therapeutic inquiry. In fact, the popularity of the Internet among adolescents presents a crucial argument for assessment of Internet use in general, as well as specific assessment of Internet exposure to self-injury. Mental health professionals should therefore educate themselves about various websites for self-injurers (some recommended sites are included in the next section).
Whitlock and her fellow researchers suggested that clinicians maintain a curious, neutral, nonjudgmental tone when asking questions such as the following:
- How comfortable do you feel hearing stories from others who self-injure?
- Have you shared your own story? How did you feel?
- What do you like most about having friends whom you really know only through the Internet?
- How honest are you when you share information on the Internet? (Do you minimize or tend to embellish?)
- Do you ever take advice from Internet friends? If so, can you provide examples of advice that you used?
Some NSSI sites have minimal or no monitoring for potentially dangerous content. If there are moderators, they typically have minimal or no training in mental health. With certain clients, counselors might assess that it is best to be direct in encouraging or discouraging particular sites or interactive behaviors. Counselors can clarify concerns about why some sites might be traumatic or triggering and therefore countertherapeutic. These direct suggestions will likely be more fruitful with adolescents who have entered counseling voluntarily, begun to develop a therapeutic relationship with the counselor and voiced a desire to stop or reduce self-injury.
In this article, several mediums have been identified as environments at high risk for social contagion of NSSI — namely group treatment, residential facilities and social media. Key considerations for the prevention of social contagion were identified. These include:
- Developing a clinical understanding of social contagion and its significant impact on the adolescent population through training and further research
- Working with clients who engage in NSSI to develop awareness of appropriate environments to discuss their self-injury stories, such as individual therapy sessions
- Asking clients who self-injure to cover up scars, wounds and bandages that can be triggering
- Prohibiting graphic detail of NSSI at the onset of group therapy
- Incorporating strength-based strategies that encourage healthy coping behaviors in treatment
- Assessing client Internet use, with specific attention paid to exposure to self-injury imagery
- Determining the appropriate level of treatment and avoiding unnecessary hospitalizations that may invoke NSSI in vulnerable clients
- Instructing clients to share stories of healing and healthy coping behaviors to decrease the opportunity for contagion, while inspiring altruistic motives in a group environment
Furthermore, the role of mental health counselors working with youth engaging in NSSI extends past the therapeutic relationship encountered in treatment to the family system and school setting to which the child is connected. Providing appropriate referrals to information for concerned individuals in the child’s life, such as parents and other caretakers, is an important action in attending to NSSI and contagion among peers. The following websites provide helpful information grounded in clinical research and professional standards.
Empowering family members and other members of the client’s care system to understand self-injury will help them to comprehend the messages sent by the child who is engaging in the behavior, while promoting an atmosphere of awareness to counteract opportunities for contagion. As a provider of information, it is crucial that the counselor is clear when it comes to appropriate Internet material, such as empirically validated information for families, and the potential misinformation provided by sites containing blogs and graphic imagery. The prevention of contagion begins with understanding NSSI in youth and empowering the people in their lives who also share in the opportunity to preclude self-injury among adolescents.
This article was adapted from a previous article published in the American Mental Health Counselors Association’s Journal of Mental Health Counseling.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
Brent G. Richardson is chair of the Department of Counseling at Xavier University in Cincinnati. Contact him at email@example.com.
Kendra A. Surmitis is an assistant professor of counseling in the Department of Educational Psychology at Northern Arizona University. Contact her at firstname.lastname@example.org.
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