TPC Journal-Vol 10- Issue 2-FULL ISSUE

The Professional Counselor | Volume 10, Issue 2 183 various mental health diagnoses for one year. The researchers analyzed the frequency and timing of particular behaviors, including NSSI, and found significant clustering of self-injurious incidents, supporting contagion for NSSI among the group. Furthermore, researchers have found that a small portion of those who engage in NSSI do so to influence others (e.g., get the attention of a particular person, manipulate others, or elicit care; Doyle et al., 2017; Nock, 2008). In light of the ubiquitous nature of the internet, NSSI social contagion may occur among online groups, as well as those that exist offline. Walsh (2012) noted that factors contributing to social contagion offline can also occur online within the context of social networking sites, message boards, chat rooms, and YouTube. Researchers have confirmed the prevalence of NSSI images and videos online. Lewis and colleagues (2011) investigated NSSI videos on YouTube and found that the top 100 NSSI videos were viewed over 2 million times. Miguel et al. (2017) found 770 NSSI-related images on three social media platforms in a 6-month period using one search term (#cutting). The researchers classified 59.5% of the images as graphic in nature (Miguel et al., 2017). Although there are potential benefits of online communication about NSSI, such as encouraging help-seeking and support, online NSSI-related images and videos pose risks as well. Lewis et al. (2012) noted that online mediums may provide reinforcement for NSSI, provide tips and strategies (such as first aid considerations), and trigger urges among users to engage in NSSI. NSSI as a Behavioral Addiction Given its seemingly compulsive nature, some authors have proposed the conceptualization of NSSI as a behavioral addiction (Buser & Buser, 2013; Davis & Lewis, 2019). Indeed, Buser and Buser (2013) posited that for some individuals, NSSI reflects the commonly used criteria for addiction, including compulsivity, loss of control, continuation despite negative consequences, relief from negative emotions, and tolerance. Specifically, tolerance to NSSI can develop as a result of frequent activation of the endogenous opioid system, to which the individual becomes less sensitive (Buser & Buser, 2013; Walsh, 2012). Tolerance among those who self-injure may manifest as increased frequency of NSSI, increased severity of skin tissue damage, or the use of additional NSSI methods (Wester & Trepal, 2017). In the content analysis of 500 posts on NSSI online message boards, Davis and Lewis (2019) determined six themes that underscored the addictive nature of NSSI: urge/ obsession, relapse, can’t/don’t want to stop, coping mechanism, hiding shame, and getting worse/ not enough. These themes indicate that some individuals who engage in NSSI experience cravings, a loss of control, urges, and relapse—all common features of addictive behaviors (American Society of Addiction Medicine, 2019). Given the growing acceptance of behavioral addictions, as evidenced by recent changes and additions to both the DSM-5 (APA, 2013) and the International Classification of Diseases ( ICD-11 ; World Health Organization, 2018), it is important to assess whether clinicians working with clients who self-injure conceptualize the behavior as addictive. Purpose of the Study Although some researchers have investigated the experience of clinicians addressing clients who self-injure (Roberts-Dobie & Donatelle, 2007; Trepal & Wester, 2007), the growing prevalence of NSSI (Mercado et al., 2017; Wester et al., 2018) warrants updated information. Therefore, we designed the current study to explore licensed clinicians’ experiences with clients who engage in self-injurious behaviors. Specifically, we sought to examine the frequency of addressing NSSI in clinical work, characteristics of clients who self-injure, NSSI assessment practices, the role of the internet in NSSI, clinicians’ beliefs pertaining to NSSI, and clinical training and competence.