Understanding Self-Injury: A Person-Centered Approach

Over the past several years, growing research and clinical attention has been paid to nonsuicidal self-injury (NSSI), the deliberate damaging of one’s body tissue for nonlethal reasons. Self-injury is a common and highly concerning mental health difficulty listed in the DSM-5 as a condition warranting further consideration (1). A review of extant literature indicates that approximately 18% of adolescents (ages 10–17 years) and 13% of emerging adults (ages 18–24 years) have self-injured; the rate is approximately 20% among university students (2). Among children, rates are about 8% among preadolescents, ages 8–12 years (1). Among adults (over 25 years of age), about 5%−6% report past self-injury (1, 2). Because self-injury is most often used to obtain relief from painful emotion, it should come as little surprise that self-injury is a transdiagnostic behavior associated with a range of mental health diagnoses (e.g., major depression, eating disorders), although self-injury is not always associated with mental illness (1). Furthermore, many individuals report scarring, which may contribute to shame and adversely affect recovery (3). Of grave concern is a growing line of inquiry indicating that self-injury is the single most reliable predictor of subsequent suicide ideation and attempts (1). Although some individuals engage in self-injury without suicidal intent, people who have self-injured are up to 5.5 times more likely than those who have not self-injured to attempt suicide (4). Therefore, self-injury needs to be taken seriously and be appropriately addressed.

Despite frequently seeing individuals who self-injure, mental health professionals report a lack of knowledge about self-injury (5). We direct this Open Forum to health care workers who serve as the initial point of contact for and play an important role in appropriately triaging and referring people who self-injure. Health professionals may include staff in emergency departments, primary care physicians, or mental health workers in other settings. In hospital settings, repeat presentation because of self-injury is common, with up to 33% of people repeating their self-injury in the year following an episode (6). As such, self-injury is seen as a challenging behavior and can lead to health care professionals feeling a sense of frustration and helplessness when working with individuals who self-injure (4). Such stressors can result in compassion fatigue (including burnout) that is strongly associated with psychological distress, reduced quality of care, and increased absenteeism (7). These factors may also underlie negative attitudes toward people who self-injure and, in some cases, suboptimal care (8, 9). Accordingly, this Open Forum offers a framework to be used in clinical work to yield better outcomes for both individuals who self-injure and health care workers who care for them. We do not offer a treatment guide but rather a new way to think about self-injury that is commensurate with recent movements in the field to adopt a person-centered approach when working with people who self-injure (3, 10, 11). Because many individuals who engage in self-injury experience a sense of being stigmatized and misunderstood (9, 11), this framework is intended for use with all individuals who self-injure.

It is important to recognize that no two individuals with lived experiences are alike; each person will have unique circumstances and needs, even if, outwardly, their circumstances and needs appear alike (3, 10). Consideration of all aspects of recovery, not just cessation of the behavior, can help minimize focus on the behavior itself and offer opportunities to recognize growth and resilience (3, 10). Together with behavior change, recovery encompasses a growing belief in the ability to resist ongoing urges to self-injure and to engage alternative coping strategies. Addressing underlying mental health concerns may also lead to a reduction in urges to self-injure. Concerns about visible scarring that may result from self-injury can elicit stigma and shame among people who self-injure (3). Adopting a person-centered approach that focuses on the unique experiences and needs of the individuals will help foster rapport, validate their experience, improve care, and, arguably, lead to increased confidence and job satisfaction for health care workers (10).