TPC Journal-Vol 10- Issue 2-FULL ISSUE

The Professional Counselor | Volume 10, Issue 2 189 images and the frequency in which they asked clients who self-injured about their internet behavior. According to the results of our survey, almost half of clinicians surveyed ( n = 42; 44.7%) did not know about the role of the internet or SNS among clients who self-injured because they did not ask. Twenty- nine (30.9%) clinicians reported that at least some of their clients used the internet to share pictures. Furthermore, 33 (35.1%) of the clinicians in our study disclosed they had never asked about SNS or the internet when assessing and treating clients engaging in NSSI, and 27 (28.7% ) reported asking less than 50% of the time. These numbers indicate a need for clinicians to have access to current research related to the prevalence of viewing and sharing NSSI images online (Lewis et al., 2011; Miguel et al., 2017). For example, Lewis and Seko (2016) thematically examined 27 empirical studies investigating the perceived effects of online behavior among those who self-injure. The authors reported both perceived benefits of online NSSI activity (i.e., mitigation of social isolation, recovery encouragement, emotional self- disclosure, and curbing NSSI urges) as well as perceived risks (i.e., NSSI reinforcement, triggering NSSI urges, and stigmatization of NSSI; Lewis & Seko, 2016). In addition, previous researchers have found that a portion of individuals engaging in NSSI do so to influence others (Doyle et al., 2017; Nock, 2008), and thus may be particularly attracted to sharing NSSI images online. Given the complex role of the internet in self-injury, it seems imperative that clinicians broach the subject with clients who self-injure. Our results also demonstrated a strong belief among clinicians ( n = 78; 83%) that NSSI can be an addictive behavior for some clients, which supports the stance of previous researchers who conceptualize NSSI as a behavioral addiction (Buser & Buser, 2013). The conceptualization of NSSI as an addictive behavior, with particular emphasis on the stimulation of the endogenous opioid system, has important implications for treatment. Evidence-based addictions treatment strategies such as 12-step support group attendance (Connors et al., 2001) and motivational interviewing (Miller & Rollnick, 2013) can be helpful approaches for working with client NSSI. Finally, we examined clinicians’ training experience and perceived competence related to NSSI. Less than half of our participants ( n = 42; 44.7%) received NSSI training in their graduate-level coursework. The number of clinicians seeking NSSI training via continuing education ( n = 55; 58.5%) and self-study ( n = 38; 40.4%) is indicative of the desire for more knowledge related to self-injury. In addition, roughly 23% ( n = 22) of our sample felt less than “somewhat competent” when addressing NSSI in their clinical work. This perceived incompetency reflects the reported lack of training related to NSSI treatment. Ultimately, this data highlights the opportunity to substantially improve NSSI training to increase clinical competence. Implications for Counselors The results of the current study have implications for clinical work with NSSI, specifically in the realms of assessment and treatment. Although many clinicians in our study reported effective assessment measures related to NSSI, an important step for improving assessment might be to include a separate NSSI item on intake forms distinct from suicidal behavior. Sixteen clinicians (17%) in our study said their intake form did not inquire about NSSI, and 22 (23.4%) said the item was written in conjunction with suicidal ideation and attempts. The combination of NSSI and suicidal thoughts or ideations on an intake form can make client conceptualization and treatment goals challenging. NSSI and suicide attempts have markedly different motives (Favazza, 1998; Walsh, 2012; Wester & Trepal, 2017); therefore, listing the behaviors as two separate intake items may best serve both clinicians and clients. Specifically, clinicians could provide a definition of NSSI (Favazza, 1998) on the form to help clients understand the terminology. For clients who indicate that they are engaging in NSSI, clinicians can then utilize formal assessment instruments or the proposed NSSI Disorder diagnostic criteria in the DSM-5 (APA, 2013) to gain a thorough understanding of the behavior. Additionally, clinicians may