Amanda Giordano, Lindsay A. Lundeen, Chelsea M. Scoffone, Erin P. Kilpatrick, Frank B. Gorritz
Nonsuicidal self-injury (NSSI) is a common clinical concern. We surveyed a national sample of 94 licensed clinicians to better understand their work with clients who self-injure. Our data revealed that over the past year, 95.7% (n = 90) of the sample reported working with at least one client who self-injured. Thirty-six clinicians (38%) reported that most or all of their clients who self-injured were adolescents, 61 (64.9%) reported that most or all clients who self-injured were female, and 43 (45.7%) reported that most or all clients who self-injured engaged in cutting as the primary NSSI method. About 35% (n = 33) of the clinicians in our sample indicated they have never asked clients who self-injured about their online activity related to NSSI. The majority of our participants (n = 78; 83%) supported the notion that NSSI could be an addictive behavior for some clients and less than half (n = 42; 44.7%) received NSSI training in their graduate coursework.
Keywords: nonsuicidal self-injury, NSSI, licensed clinicians, training, behavioral addiction
Nonsuicidal self-injury (NSSI) is a complex phenomenon. Favazza (1998) defined NSSI as “the deliberate, direct destruction or alteration of body tissue without conscious suicidal intent” (p. 260). The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) noted that NSSI is intentional and self-inflicted body damage that is not socially sanctioned (e.g., piercings or tattoos) and lacks suicidal intent. The fact that NSSI is intentional and direct distinguishes it from unplanned or indirect forms of self-harm such as disordered eating or substance abuse (Favazza, 1998; Walsh, 2012). Furthermore, although a relationship exists, NSSI is distinct from suicide attempts in that it is a means of seeking relief and coping, thereby sustaining rather than ending one’s life (Walsh, 2012; Wester & Trepal, 2017). NSSI has been conceptualized as a behavioral addiction (Buser & Buser, 2013) given that some clients demonstrate a loss of control over NSSI, continued engagement despite negative consequences, craving to engage in NSSI, and compulsivity, which are hallmarks of addiction. Also, researchers have found evidence for NSSI contagion, in which the behavior is imitated by others in a specific community (Walsh, 2012; Walsh & Rosen, 1985). Given these complexities, it is imperative that clinicians are adequately trained to assess and treat NSSI.
In light of previously published prevalence rates, it is likely that most clinicians will work with clients who self-injure at some point in their careers. Indeed, 21%–80% of inpatient clients and 22%–40% of outpatient clients have reported engagement in self-injurious behavior (Wester & Trepal, 2017). Moreover, in a national sample of 74 clinical practitioners, 60 (81%) reported working with clients who self-injured (Trepal & Wester, 2007), and among 443 school counselors, 357 (81%) reported working with at least one student engaged in self-injury (Roberts-Dobie & Donatelle, 2007). Much has changed, however, in the social landscape related to self-injury, including the popularity of sharing NSSI images online; television shows, movies, and songs depicting NSSI; and celebrities disclosing NSSI behavior. Thus, we sought to investigate licensed clinicians’ experiences working with clients who self-injure to provide updated information and better inform the profession of counseling.
Terminology and Prevalence of NSSI
NSSI is not a new abnormal behavior. Indeed, it was documented in the gospel account of Mark written between A.D. 55 and 65, in which the author described a man cutting himself with stones (Mark 5:5; NIV Life Application Study Bible, 1984). Self-injurious behavior has been labeled self-mutilation, self-harm, deliberate self-harm, parasuicide, cutting, and non-suicidal self-directed violence (Wester & Trepal, 2017). In this paper, we use the term nonsuicidal self-injury (NSSI) as it is currently listed as the proposed diagnosis in the DSM-5 (Section III, Conditions for Further Study; APA, 2013).
Current prevalence rates indicate that NSSI affects a substantial portion of the population, particularly female adolescents (Nock, 2009; Wester & Trepal, 2017). For example, in a study of 665 adolescents, researchers determined that 8% engaged in NSSI at some point in their lives, which included 9% of the females in the sample and 6.7% of the males (Barrocas et al., 2012). Furthermore, Doyle and colleagues (2017) surveyed adolescents in Ireland and found that 12% had engaged in NSSI, the majority (72.8%) of which were female. Moreover, the examination of data from emergency room visits among youth in the United States (10–24 years of age) indicated a rise in non-fatal self-inflicted injury among females (with and without suicidal intent) from 2001 to 2015 (Mercado et al., 2017). Specifically, self-inflicted injuries with a sharp object rose from 261 incidents in 2001 to 1,021 incidents in 2015 (Mercado et al., 2017). Along with adolescent populations, NSSI is a growing concern among young adults. Wester et al. (2018) examined NSSI among three cohorts of freshman college students and found that lifetime NSSI increased from 16% in the 2008 cohort to 45% in the 2015 cohort. Additionally, current NSSI increased from 2.6% in the 2008 cohort to 19.4% in the 2015 cohort (Wester et al., 2018).
Motives for NSSI
The function of NSSI can be challenging to comprehend among those who do not engage in the behavior. Criterion B in the proposed criteria for NSSI Disorder in the DSM-5 (APA, 2013) highlighted three potential functions: (a) to relieve negative feelings and cognitions, (b) to address relational difficulties, and (c) to stimulate positive feelings. Indeed, emotion regulation is a primary motivation for NSSI (Nock, 2009). Among 108 adolescents in inpatient treatment who engaged in self-injurious thoughts or behaviors, Nock and Prinstein (2004) found 52.9% engaged in NSSI to relieve negative emotions, 34.1% engaged to feel something, and 30.6% engaged as a form of self-punishment. Doyle et al. (2017) found 79% of adolescents who engaged in NSSI did so to find relief from negative emotions or cognitions, 38% engaged to punish themselves, and 35% sought to communicate the extent of their distress. In light of the many means of emotion regulation that exist, Nock (2009) identified three reasons why some individuals choose NSSI: (a) as a result of social learning from the media, friends, and family; (b) as a form of punishment via self-directed abuse; and (c) as a means of social signaling, or communicating with others (particularly when other forms of communication were ineffective). Engaging in NSSI may be a more accessible, affordable, and easy-to-hide method of emotion regulation compared to other strategies such as substance abuse (Nock, 2009).
NSSI Social Contagion
One important consideration related to NSSI is social contagion, or the engagement in a behavior by at least two people in a group within 24 hours (Jarvi et al., 2013; Walsh, 2012; Walsh & Rosen, 1985; Wester & Trepal, 2017). Individuals can become exposed to NSSI through peers, family members, media, and song lyrics, which contribute to social learning (Jarvi et al., 2013; Nock, 2009) and potentially sensationalize the behavior (Walsh, 2012). In a review of the literature, researchers found 16 studies supporting the association between social contagion and NSSI (Jarvi et al., 2013). In a seminal work, Walsh and Rosen (1985) studied the behavior of 25 adolescents in treatment for 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.
Our sample consisted of 94 licensed clinicians in the United States. Participants ranged in age from 26 to 70 years old with a mean age of 45 (SD = 11.06). Eighty (85.1%) participants identified as White, six (6.4%) as Black/African American, three (3.2%) as biracial/multiracial, three (3.2%) as other, and two (2.1%) as Latino(a)/Hispanic. With regard to gender, 79 (84%) participants identified as female, 13 (13.8%) as male, one (1.1%) as transgender, and one (1.1%) as other. Of the 94 participants, 82 (87.2%) identified as heterosexual, five (5.3%) as bisexual, three (3.2%) as queer, two (2.1%) as lesbian, and one (1.1%) each as gay and other.
In relation to professional background, the clinicians represented varying degree levels and educational fields of study. Most of the participants’ highest degree was a master’s (n = 86; 91.5%), while seven (7.4%) earned a doctoral degree, and one (1.1%) participant earned a specialist degree. Fifty-six (59.6%) of the participants reported that their highest degree was from a CACREP-accredited program, while 26 (27.7%) of the participants came from a non–CACREP-accredited program, and 12 (12.8%) did not answer the question. Some diversity existed among participants’ programs of study and licensure: 51 (54.3%) participants studied professional counseling or counselor education, 27 (28.7%) studied counseling psychology, seven (7.4%) studied clinical psychology, six (6.4%) studied other areas not listed, and three (3.2%) studied rehabilitation counseling. In terms of licensure, 47 (50%) participants were licensed professional counselors (LPCs), 19 (20.2%) were licensed mental health counselors (LMHCs), 15 (16%) were licensed professional clinical counselors (LPCCs), 11 (11.7%) held licensures not listed in our questionnaire, 11 (11.7%) were licensed clinical professional counselors (LCPCs), seven (7.4%) were licensed clinical mental health counselors (LCMHCs), four (4.3%) were licensed professional counselors of mental health (LPCMHs), three (3.2%) were licensed marriage and family therapists (LMFTs), and one (1.1%) was a licensed chemical dependency counselor (LCDC).
The participants had varying years of clinical experience. Eighteen (19.1%) participants had been counseling clients for 1–5 years, 43 (45.7%) for 6–10 years, 17 (18.1%) for 11–15 years, six (6.4%) for 16–20 years, three (3.2%) for 21–25 years, five (5.3%) for 26–30 years, and two (2.1%) for more than 30 years. All participants stated they were currently seeing clients. We asked participants to describe their typical client base by selecting all applicable responses: 84 (89.4%) of the participants counseled adults, 37 (39.4%) counseled adolescents, 37 (39.4%) counseled college students, 27 (28.7%) counseled couples, 19 (20.2%) counseled children, and 12 (12.8%) counseled families.
Similar to the approach employed by Trepal and Wester (2007), our questionnaire consisted of two sections: participants’ demographics and clinical experiences with NSSI. In the demographics section, we assessed participants’ age, race, ethnicity, gender, sexual orientation, education, clinical license, and typical client base. Next, to better understand clinical work with clients who self-injure, we compiled a series of descriptive, Likert-type assessment items. Specifically, the questionnaire items explored how often clinicians addressed issues of NSSI in counseling, characteristics of clients who self-injured, methods of assessing NSSI, clients’ internet and social networking activity pertaining to self-injury, the extent to which clinicians conceptualized NSSI as an addiction and whether NSSI should be a formal diagnosis included in the DSM proper (rather than as an appendix), extent of clinical training pertaining to NSSI, and perceived clinical competence when working with issues of NSSI among clients. In sum, the questionnaire contained 22 items related to clinical work with NSSI.
We acquired our national sample of licensed clinical participants using the clinician database on the Psychology Today website. Specifically, we conducted a search of clinicians with experience addressing a general clinical issue (i.e., anxiety) within each of the 50 states. We identified the names of the first 13 licensed clinicians from each state and searched the internet for their email addresses. If an email address could not be found, we replaced this clinician with the next licensed clinician listed on the Psychology Today website for that particular state. We continued this process until we had names and email addresses for 13 licensed clinicians from each state, yielding 650 potential participants.
We calculated a desired sample of 650 given that researchers purported an average response rate of 15.7% for online research surveys sent to professional counselors in the “other” category (members of state-level associations), which most closely reflected our sample (Poynton et al., 2019). After receiving approval from the Institutional Review Board, we emailed the questionnaire link utilizing the Qualtrics software program to the 650 potential participants. Fifty-two emails were undeliverable, resulting in 598 emails sent. We sent participants three reminder emails over the course of three weeks. We received 102 questionnaires (17.1% response rate) from our national sample of licensed clinicians. After removing eight unfinished questionnaires, our final sample consisted of 94 participants (adjusted response rate = 15.7%).
To answer our research questions regarding licensed clinicians’ experiences with client NSSI, we assessed descriptive data resulting from responses to our questionnaire. The data fell into six broad categories: (a) frequency of NSSI in clinical work, (b) descriptions of clients who self-injure, (c) assessment of NSSI, (d) role of the internet, (e) clinicians’ beliefs about NSSI as an addiction and formal diagnosis, and (f) NSSI-related training and perceived competence.
Frequency of NSSI in Clinical Work
We first sought to examine how frequently licensed clinicians worked with clients who self-injured. Specifically, we asked our sample how often in the totality of their clinical work they addressed client NSSI. Results indicated that only two (2.1%) clinicians had never worked with a client reporting NSSI, 37 (39.4%) addressed NSSI rarely (about 10% of the time), 33 (35.1%) addressed NSSI occasionally (about 30% of the time), 13 (13.8%) addressed NSSI a moderate amount (about 50% of the time), five (5.3%) addressed NSSI frequently (about 70% of the time), and four (4.3%) addressed NSSI almost always (about 90% of the time). Thus, among a national sample of 94 licensed clinicians, 92 (97.9%) reported working with NSSI at some point in their careers, with 55 (58.5%) reporting that they addressed NSSI 30% of the time or more.
We also assessed frequency of NSSI among clients in the past year. Only one (1.1%) clinician reported not having self-injuring clients in the previous 12 months. Fifty-one (54.3%) clinicians worked with 1–5 clients who self-injured, 24 (25.5%) worked with 6–10 clients who self-injured, six (6.4%) worked with 11–15 clients who self-injured, and nine (9.6%) worked with more than 15 clients who self-injured. Three (3.2%) participants did not respond to this item.
Descriptions of Clients Who Self-Injure
We then examined clinicians’ descriptions of clients who reported NSSI. Specifically, we inquired about age, gender, race, and method of self-harm by asking clinicians what portion of their clients who self-injured fell into various categories (Table 1). Sixty-one (64.9%) clinicians reported that most or all of their clients who self-injured were female, five (5.3%) reported that most or all of their clients who self-injured were transgender, and one (1.1%) reported that most or all clients who self-injured were male. With regard to race, 63 (67.0%) clinicians reported that most or all of their clients who self-injured were White and nine (9.6%) clinicians reported that most or all of their clients who self-injured were members of a marginalized racial group. With regard to age, 36 (38.3%) clinicians reported that most or all of their clients who self-injured were adolescents, 31 (33.0%) reported that most or all of their clients who self-injured were adults, and one (1.1%) reported that most or all of their clients who self-injured were children. In terms of method of self-injury, 43 (45.7%) clinicians reported that most or all of their clients who self-injured engaged in cutting and seven (7.4%) clinicians reported that most or all of their clients who self-injured engaged in self-injurious behavior other than cutting (e.g., burning, hitting, scratching, punching). Therefore, the experience of NSSI is diverse. Although a substantial portion of clinicians reported that the majority of clients presenting with NSSI were White female adolescents who engaged in cutting, numerous clinicians indicated some clients (up to 50%) were male or transgender, children or adults, clients of color, and engaged in methods other than cutting.
Number of Clinicians Endorsing Each Response
|Item: Among your clients who self-injure, what portion are:
( < 50%)
|About half (50%)
( > 50%)
|Person of Color
|Engaged primarily in cutting
|Engaged primarily in self-injurious behavior other than cutting
Note. Numerical values refer to number of clinicians endorsing that response, followed by percent of clinicians out of the total (N = 94); percentages do not equate to 100 because of missing items: female (missing 3), male (missing 4), transgender (missing 4), White (missing 3), person of color (missing 2), children (missing 5), adolescents (missing 2), adults (missing 4), primarily cutting (missing 3), primarily other behavior (missing 2).
Assessment of NSSI
We also examined data related to the clinical assessment of NSSI. The most commonly endorsed form of assessing NSSI among clinicians was informal assessment through dialogue (n = 83, 88.3%), followed by the use of formal NSSI assessment instruments (n = 21, 22.3%). One (1.1%) clinician reported never assessing NSSI in their clinical work. We also inquired as to whether or not clinicians’ intake forms contained items related to NSSI. Forty-six (48.9%) reported yes, the NSSI item was separate from suicide items; 22 (23.4%) reported yes, the NSSI item was in conjunction with suicide attempts; 16 (17.0%) clinicians reported no, their intake form did not have an item related to NSSI; and 10 (10.6%) did not know or did not answer this question.
Role of the Internet in Client Self-Injurious Behavior
We investigated participants’ responses to items related to clients’ internet use related to NSSI. Specifically, we asked clinicians what portion of their clients engaging in NSSI utilized the internet or social networking sites (SNS) to share pictures of self-injury. Forty-two (44.7%) clinicians reported they did not know because they never discussed the issue with their clients who self-injured. Twenty-six (27.7%) clinicians reported that some (up to 50%) of their clients who self-injured shared NSSI pictures online, 20 (21.3%) reported none of their clients who self-injured shared NSSI pictures online, and three (3.2%) reported that half to all of their clients who self-injured shared NSSI pictures online. In response to the item assessing the frequency in which clinicians asked clients who self-injured about their internet and SNS use related to self-injury, 33 (35.1%) clinicians reported they never asked about this topic, 27 (28.7%) asked sometimes (less than 50% of the time), seven (7.4%) asked about half the time, 17 (18.1%) asked most of the time (more than 50%), and eight (8.5%) always asked. Therefore, it appears that clinicians do not consistently inquire about clients’ internet and SNS use as it relates to NSSI, but those who do find that some of their clients share pictures of self-injury online.
Clinicians’ Beliefs About NSSI
In light of the current status of NSSI Disorder as a condition for further study in the DSM-5 (APA, 2013) and debate about the addictive nature of NSSI, we asked clinicians to share their beliefs on these two topics. With regard to diagnostic status, 32 (34%) clinicians believed NSSI Disorder should be a formal diagnosis in the next edition of the DSM, 24 (25.5%) did not have a preference, and 13 (13.8%) did not believe it should be a diagnosis. Twenty-five (26.6%) participants did not respond to this item. Pertaining to the conceptualization of NSSI as an addiction, 78 (83.0%) clinicians believed that for some individuals, NSSI can be an addiction; eight (8.5%) did not believe NSSI could be an addiction; six (6.4%) stated they did not know; and two (2.1%) did not answer this item. Thus, it appears that one third of the sample supported a formal diagnosis of NSSI Disorder in the DSM proper and a large majority of the sample agreed that NSSI could be an addictive behavior.
NSSI-Related Training and Competence
Finally, participants reported settings in which they received training to address NSSI in clinical work (participants could select all modalities that applied). The most common training modality was continuing education (e.g., conference presentations, workshops, seminars), which was endorsed by 55 (58.5%) clinicians. On-the-job training was the second most common modality, endorsed by 47 (50.0%) clinicians, followed by graduate school coursework, endorsed by 42 (44.7%) clinicians; self-study, endorsed by 38 (40.4%) clinicians; and graduate school internships, endorsed by 28 (29.8%) clinicians. Three (3.2%) clinicians reported that they had never received NSSI training. Clinicians further reported the extent to which they felt competent addressing NSSI in counseling. Four (4.3%) clinicians felt extremely incompetent, eight (8.5%) felt somewhat incompetent, 10 (10.6%) felt neither competent nor incompetent, 54 (57.4%) felt somewhat competent, and 17 (18.1%) felt extremely competent. One (1.1%) clinician did not respond to this item. Overall, clinicians primarily received NSSI training via continuing education workshops and on-the-job experiences. About half of our sample felt somewhat competent to address NSSI, indicating opportunities to improve NSSI training and competence among clinicians.
Given the rising prevalence of NSSI (Mercado et al., 2017; Wester et al., 2018) and new considerations such as social contagion (Walsh, 2012; Walsh & Rosen, 1985) and sharing NSSI images online (Lewis et al., 2011; Miguel et al., 2017), continued research is needed related to clinical work with self-injury. We disseminated a questionnaire among a national sample of licensed clinicians to examine the prevalence of NSSI, descriptions of clients who engage in NSSI, means of assessing NSSI, role of the internet in NSSI behaviors, clinicians’ beliefs about NSSI, and NSSI training and perceived competence. Our results indicated that most clinicians surveyed (n = 92, 97.9%) have worked with at least one client who engaged in NSSI. This prevalence rate suggests a potential increase in the presenting concern since Trepal and Wester’s (2007) study, in which 81% of practicing counselors reported working with a client who self-injured during their careers. Furthermore, our results revealed that 95.7% (n = 90) of clinicians treated at least one client participating in NSSI within the past year. Although researchers have determined that 8% of adolescents (Barrocas et al., 2012) and 45% of college freshman (Wester et al., 2018) in naturalistic samples engaged in NSSI at some point in their lifetimes, it appears the frequency might be higher among clients seeking counseling services.
Previous researchers have established that NSSI is more prevalent among females than males (Barrocas et al., 2012; Doyle et al., 2017; Mercado et al., 2017). Our results confirmed these findings as 61 (64.9%) of the clinicians in our sample indicated that most or all of their clients who self-injured were female, as compared to only one (1.1%) who said most or all were male. It is important to note, however, the prevalence of clinicians who reported working with male clients who self-injured. Specifically, 57 (60.6%) noted that some of their clients who self-injured were male and 11 (11.7%) reported that about half of their clients who self-injured were male. Thus, these results indicate that although NSSI is more prevalent among females, it also occurs among male populations. Additionally, although NSSI typically begins in adolescence (Nock & Prinstein, 2004; Wester & Trepal, 2017), 31 (33%) of the clinicians in our sample reported that most or all of their clients who engaged in NSSI were adults. It is imperative, therefore, that clinicians who work with both adolescents and adults are prepared to effectively screen for and treat NSSI.
Regarding the assessment of self-injurious behaviors, our results revealed that only 21 (22.3%) clinicians utilized formal NSSI assessments. Although informal assessment measures often are effective, clinicians could benefit from reviewing psychometrically sound NSSI assessment instruments such as the Deliberate Self-Harm Inventory (Gratz, 2001), the Alexian Brothers Urge to Self-Injure Scale (ABUSI; Washburn et al., 2010), or the Non-Suicidal Self-Injury-Assessment Tool (Whitlock et al., 2014; see Wester & Trepal, 2017, for an extensive description of multiple NSSI assessments).White Kress (2003) summarized that clinicians should assess the function, severity, and dynamics of NSSI, including age of onset, emotions while engaging in NSSI, antecedents to NSSI, desire and efforts to stop or control NSSI, use of substances while self-injuring, medical complications, and changes over time.
We also sought to understand the role of the internet and SNS in NSSI behaviors. Specifically, we inquired of licensed clinicians the extent to which their clients utilized the internet or SNS to share NSSI 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 best serve clients by assessing NSSI with all individuals, regardless of gender, age, racial, or ethnic identification, by asking a broad question such as “Have you ever deliberately hurt yourself?” rather than “Have you ever cut yourself?” to be inclusive of multiple forms of NSSI.
With regard to treatment strategies for NSSI, several useful approaches exist. Dialectical behavior therapy (Linehan, 1993) is a counseling method combining cognitive-behavioral and mindfulness techniques for work with clients diagnosed with borderline personality disorder (BPD). NSSI can be associated with BPD given that self-mutilation is listed as a diagnostic criterion for the disorder (APA, 2013). Researchers have found empirical support for the efficacy of dialectical behavior therapy with regard to NSSI (Choate, 2012; Muehlenkamp, 2006); thus, this treatment approach may be useful for clients with BPD and NSSI. Self-injury also can exist apart from a BPD diagnosis (Muehlenkamp, 2005). In these instances, treatment for self-injurious behavior (T-SIB; Andover et al., 2015) may be a useful approach. T-SIB is a 9-week intervention designed for young adults who self-injure. The intervention includes providing psychoeducation, increasing motivation to change, conducting functional analysis, developing replacement behaviors, increasing distress tolerance, and cognitive restructuring (Andover et al., 2015, 2017). Some empirical support exists for the efficacy of T-SIB among young adults, and the treatment manual provides detailed information for clinicians using the approach (Andover et al., 2015, 2017).
Regardless of the therapeutic intervention, it would behoove clinicians to inquire about clients’ online activities related to NSSI to inform treatment plans and goals. Clients’ online activities could include watching NSSI videos; viewing NSSI images; posting and sharing NSSI images on SNS; communicating with others who self-injure via chatrooms and NSSI websites; or seeking information related to how to conceal, clean, or perform NSSI. As part of their recovery plan, it may be helpful for clients and counselors to develop strategies for healthy online behaviors to minimize triggers, urges, or the normalization of NSSI. Even for clients who describe using the internet to find support for their NSSI, clinicians have the opportunity to describe potential risks with NSSI online activity as well (Lewis & Seko, 2016).
Limitations and Future Research
This study is not without limitations. First, our final participant sample consisted of only 94 licensed clinicians, which reflected a 15.7% response rate. Although this is fairly typical for online surveys (Poynton et al., 2019), there were many potential respondents who did not participate, and we were unable to determine if non-respondents differed significantly from respondents. Additionally, in order to obtain a nationally representative sample, we utilized the clinician database found on Psychology Today. Thus, our participants were limited to only those clinicians who registered for that particular website. Furthermore, although our questionnaire was robust, we did not inquire about the nature of internet use among clients with NSSI. Future researchers may choose to assess whether clients primarily use the internet for education related to NSSI, to find support, to share images, or to read others’ accounts of NSSI behaviors. Finally, we utilized only licensed clinicians for this study. Future researchers may choose to replicate this study with specific types of counselors such as school counselors, inpatient counselors, and outpatient counselors to assess experiences with individuals who self-injure. In these various settings, researchers may inquire as to how clinicians code for NSSI, given that it is not included in the DSM-5 proper.
Nonsuicidal self-injury is a prevalent concern among clients seeking clinical services. We sought to understand clinicians’ experiences working with NSSI by surveying a national sample of licensed practitioners (N = 94). As demonstrated by our results, NSSI affects individuals across age ranges and gender identifications, although it is most prevalent among White female adolescents. Our findings indicate that the majority of clinicians (97.9%) worked with at least one client who engaged in NSSI in the past year. Furthermore, the majority of our sample (83.0%) supported the stance that NSSI can be an addictive behavior. Finally, our study indicates a need for more training related to NSSI in graduate programs and an emphasis on differentiating between NSSI and suicide attempts on intake forms and in clinical work.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Amanda Giordano, PhD, LPC, is an assistant professor at the University of Georgia. Lindsay A. Lundeen, MS, NCC, is a doctoral student at the University of Georgia. Chelsea M. Scoffone, MEd, is a doctoral student at the University of Georgia. Erin P. Kilpatrick, MS, NCC, LPC, is a doctoral student at the University of Georgia. Frank B. Gorritz, MS, NCC, is a doctoral student at the University of Georgia. Correspondence may be addressed to Amanda Giordano, 422G Aderhold Hall, 110 Carlton Street, Athens, GA 30602, email@example.com.
Kelly Emelianchik-Key, Rebekah J. Byrd, Amanda C. La Guardia
Self-injury is a significant issue with a variety of psychological, social, legal and ethical consequences and implications (Froeschle & Moyer, 2004; McAllister, 2003; Nock & Mendes, 2008; White Kress, Drouhard, & Costin, 2006). Self-injurious behavior is commonly associated with the cutting, bruising or burning of the skin. It also can include trichotillomania, interfering with wound healing and extreme nail biting (Klonsky & Olino, 2008; Zila & Kiselica, 2001). In assessing severity, it is important to note that self-inflicted wounds typically do not require any medical attention, as those who engage in self-injury will usually care for any open wounds in order to prevent infection (Walsh, 2006). The typical duration of a self-injurious act is usually less than 30 minutes, resulting in immediate relief from the emotional turmoil precipitating the behavior (Alderman, 1997; Gratz, 2007). It is difficult to estimate the prevalence of self-injury for many reasons. Nock (2009) noted that reports indicating increased estimates in this behavior derive from “anecdotal reports and estimates from small cross-sectional studies” (p. 81). Given the many ethical and legal ramifications involved in working with clients that self-injure, it is important to understand how self-injury typically manifests itself, how it affects differing populations based on gender and cultural differences, and the level of danger it truly represents to the person choosing to utilize it.
Self-Injury and Suicidal Intent
The current average age of those beginning to engage in self-injury is as early as 12 years old, but onset typically begins in adolescence (Lundh, Karim, & Quilisch, 2007; Trepal & Wester, 2007). Self-injury is found as a frequently occurring issue in the adolescent population (Jacobson, Muehlenkamp, Miller, & Turner, 2008; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). The majority of reported self-injury and research regarding it has been focused on Caucasian females. Within this particular population, self-injury is typically not associated with increased danger beyond the injury itself unless onset co-occurs with a psychotic episode or is co-morbid with suicidal ideation (Conaghan & Davidson, 2002; Walsh, 2006). Self-injury is the intentional harm to one’s self (usually in the form of cutting, burning, or hitting) to alleviate distress and regulate emotions (Nock & Favazza, 2009) with no intent to die. Usually, reporting of self-injury is necessitated by the concern that the act may possibly result in unintentional death; however, practitioners often simply confuse the behavior with suicidal intention (McAllister, 2003; Trepal & Wester, 2007). Suicide attempts and intention are clearly defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) as those that have the intent or aim to die. Self-injurious behaviors should be viewed as a form of self-help or coping to assist the person in feeling something different, instead of a suicide attempt (Favazza, 1998; Klonsky, 2007). A lack of consensus among researchers regarding the defining qualities of self-injurious behaviors has led to difficulty in discerning the difference between self-injury and suicide (Gratz, 2004; McAllister, 2003; Simeon, Favazza, & Hollander, 2001). As self-injury and other self-harming behaviors continue to be identified, researched and understood, new methods of evaluating these behaviors are developed. Suicide and self-injury are typically two different behaviors but often are aggregated in reports and evaluations. It was determined that data regarding the evaluation of risky adolescent behaviors might be useful for providing a tentative source for analysis. Given that self-injury, self-harm, and suicide attempts are a growing area of study, reliance on current and previous data sources for analysis of self-injury and self-harm behaviors can be used in order to highlight possible areas for research. Data from the Youth Risk Behavior Survey (YRBS; CDC, 2006), as gathered by the Centers for Disease Control and Prevention (CDC), has been used for the purpose of determining the prevalence of possible self-injurious behaviors among young women and young men from differing ethnic backgrounds.
Studies indicate mixed views on the degree of overlap between self-injury and suicidal ideation; therefore, data pertinent to the YRBS may only encompass youths within this overlap. Pattison and Kahan (1983) found that only 41% of those who self-injure reported suicidal ideation while self-injuring. “Another problem with much of the current literature is that little differentiation is made between self-injury and suicide attempts, which are very distinct behaviors” (Roberts-Dobie & Donatelle, 2007, p. 258). Therefore, it could be argued that if practitioners cannot clearly make a distinction between self-destructive acts, then adolescents reporting their behaviors might not be able to make the distinction between self-injurious intent and other possible intentions, such as suicide and frequent aggressive behaviors resulting in harm. Roberts-Dobie and Donatelle (2007) went on to state: “Self-injury is not a failed suicide attempt but often a coping mechanism for negative emotions” (p. 258). This conclusion also is shared by many researchers evaluating self-injury (Brown, Williams, & Collins, 2007; Gratz & Roemer, 2008; Klonsky, 2007; Marx & Sloan, 2002). The International Society for the Study of Self-Injury (ISSS), established in 2006, sought to clarify and understand self-injury and specifically define non-suicidal self-injury (NSSI). Following is their agreed upon definition:
The deliberate, self-inflicted destruction of body tissue resulting in immediate damage, without suicidal intent and for purposes not socially sanctioned. As such, this behavior is distinguished from: suicidal behaviors involving intent to die, drug overdoses, and other forms of self-injurious behaviors, including culturally-sanctioned behaviors performed for display or aesthetic purposes; repetitive, stereotypical forms found among individuals with developmental disorders and cognitive disabilities, and severe forms (e.g., self-immolation and auto-castration) found among individuals with psychosis. (ISSS, 2007)
It is important to note, however, that while there is a link between suicide and self-injury, it is a complicated relationship. Therefore, clinicians should always assess for suicidality when confronted with client self-injurious behaviors; however, immediately assuming suicide ideation or an active suicide attempt from reported self-injurious behavior can be therapeutically problematic. The essence of this complication presents a limitation in the analysis of the YRBS behavior data (CDC, 2006).
Treatment of Self-Injury
If self-injury is left untreated, increased severity and possible suicidality or suicide attempts may occur; therefore, it is important to recognize self-injury and treat the client appropriately and quickly in order to prevent complications. Knowledge with regard to possible presentation of self-injurious behavior as it pertains to intersections of gender, age and ethnicity also is important. Additionally, clinicians must recognize typical signs of self-injurious behaviors in relationship to diagnostic criteria. The likelihood of self-injurious behavior as a coping mechanism becomes more prevalent within certain psychological issues. The diagnoses most commonly associated with self-injury include major depression, borderline personality disorder, post-traumatic stress disorder and eating disorders (Klonsky & Muehienkamp, 2007; Marx & Sloan, 2002; Nehls, 1998; Sansone & Levitt, 2002; Sargent, 2003). Self-injury has been found to be associated with acute stress related to relational aggression, abuse and dating violence (Hays, Craigen, Knight, Healey, & Sikes, 2009; Turnage, Jacinto, & Kirven, 2003). Since self-injury also can be co-morbid with suicidality, selected psychological and emotional states will be reviewed separately in terms of their individual indicators related to self-injury, and their effects on the severity of possible danger or harm to provide a framework for the importance of data related to populations not typically studied in association with self-injurious behaviors.
Self-injury has commonly been associated with the diagnosis of borderline personality disorder (BPD), although this association may relate more to ongoing trauma issues (Alderman, 1997; Naomi, 2002). Given the continued prevalence of the diagnosis in relation to self-injury, attention to self-injury with BPD is warranted. Those who are diagnosed with BPD, or display borderline features, and are engaging in self-injury typically display other self-destructive behaviors and decision making (Gratz, 2006; Sansone, Wiederman & Sansone, 1998), tend to have unresolved anger that is noticeable in everyday relations, and also may exhibit a need to distract themselves from their emotions (M. Brown, Comtois, & Linehan, 2002). These characteristics will be prominent over other clinical symptoms associated with BPD. BPD also is more commonly diagnosed among females, as is self-injurious behavior (Lundh et al., 2007). If indeed self-injurious behaviors are associated with a history of trauma, perhaps the presentation of self-injurious behaviors are overlooked when working with male clients due to the association of self-injury with BPD.
Gender and Self-Injury
Potential gender differences in the presentation of self-injury may exist for various reasons. Past studies focusing on particular forms of self-injury have focused on potentially unrepresentative female-only samples, thus misrepresenting the existence of a more diverse population of those engaged in self-injurious behaviors (Marchetto, 2006). Some research proposes that males are just as likely as females to self-injure and perhaps go about it differently or are more secretive (Gratz, 2001). Marchetto’s study of 516 individuals engaged in skin-cutting as a form of self-injury found “no evidence for an overrepresentation of women” (p. 453). Other research supports this notion that there may not be a gender difference among certain types of self-injurious behavior (Izutsu et al., 2006; Muehlenkamp & Gutierrez, 2007). In addition, a recent study found no gender differences in prevalence of self-injury among college students, but noted that far fewer men were willing to complete the study (Heath, Toste, Nedecheva, & Charlebois, 2008). Furthermore, these authors warned against inaccurately interpreting the above issues as meaning a lower prevalence of self-injury exists among males. Seemingly, female adolescents are more likely to self-report instances of self-injury than male adolescents (Heath, Schaub, Holly, & Nixon, 2008), and male self-injurers are not diagnosed and conceptualized the same as females that self-injure (Healey, Trepal, & Emelianchik-Key, 2010). With these two compounding factors, males that self-injure are at a disadvantage to receive help with their self-injurious behaviors.
The information presented in this article is posed to present further evidence that suggests male self-injury exists and needs to be addressed in the assessment and treatment of presenting issues related to self-injury. Since depression is sometimes associated with suicidal ideation, self-injury and other harmful behaviors, recognition of the severity of client depressive symptoms through thorough assessment techniques becomes vital to treatment and selection of therapeutic interventions regardless of gender. Suicide is the third leading cause of death in adolescents and young adults, with 15% of those suffering from clinical depression ending their lives (Suicide Awareness Voices of Education, 2008). Symptoms, as outlined by the National Institute of Mental Health (2009), include and compare the early signs of making statements of prolonged despair or expressions of guilt as critical indicative signs of concrete plans for a suicide attempt. Occurrence of these signs becomes a major factor in assisting with assessment of severity. Suicidality has been linked to substance abuse, anxiety, mood disturbance and disruptive behaviors (Linehan, Comtois, Brown, Heard, & Wagner, 2006; Nock & Banaji, 2007; Wade & Pevalin, 2005). Risk factors that have been identified as highly correlated with successful suicide attempts include highly aggressive behaviors with a history of aggression, psychosis, impulsivity and bi-polar disorder (Renaud, Berlim, McGirr, Tousignant & Turecki, 2008). Becker and Grilo (2007) demonstrated that gender differences impacted how each risk factor affected the severity of the depression; however, low self-esteem was correlated with suicidality across both male and female populations. This article will use data from the YRBS and analyze it to provide empirical evidence for why issues of diversity need to be addressed within the self-injury and suicidality literature.
The YRBS is a national school-based survey developed by the CDC in order to monitor issues such as obesity, substance abuse, dietary habits, and unintentionally injurious and violent behaviors. Data files are made available to the public after analysis is completed through the CDC; data from the 2005, 2009, 2011 and 2013 surveys were used in this analysis.
As per the YRBS (CDC, 2005, 2009, 2011, 2013), at the school level, all regular public, Catholic, and other private school students, in grades 9 through 12, in the 50 States and the District of Columbia were included in the sampling frame. Puerto Rico, the trust territories, and the Virgin Islands were excluded. Schools were selected systematically with probability proportional to enrollment in grades 9 through 12 using a random start. All classes in a required subject or all classes meeting during a particular period of the day, depending on the school, were included in the sampling. Systematic equal probability sampling with a random start was used to select classes from each school that participated in the survey. In 2005, the overall response rate was 67% (158 schools participated); in 2009 the school response was 81% (158 participated); in 2011 it was 81% (158 participated); and in 2013 the response rate was 77% (148 participated). In total, 59,335 student responses were included in the datasets evaluated for the database review of behaviors associated with NSSI.
YRBS (2005, 2009, 2011, 2013) data were retrieved from the CDC in order to analyze the relationship between depression and self-injurious behaviors, including direct bodily self-injury or frequent aggressive behavior that resulted in bodily injury. The YRBS was designed to monitor health risk behaviors for adolescents in high school. For this analysis, comparisons were made with regard to gender and ethnicity to evaluate issues related to possible self-injurious behaviors, since the YRBS does not differentiate between suicidal attempts and self-injurious behaviors. Data screening methods also were used to evaluate the variables used in the study to assure they met the criteria for logistic regression. Cases with missing data for the self-injury and self-injurious aggression items were excluded.
To assess for possible NSSI, items that pertained to self-injury and self-injurious aggression within the YRBS were pulled and re-coded into dichotomous variables to include the following questions: “During the past 12 months, how many times did you actually attempt suicide?” and “If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?” If the participant attempted suicide six or more times but the injury did not require medical attention, the behavior was considered to possibly represent NSSI, since self-injury has been shown to have overlapping qualities with suicidal attempts and is not easily recognizable or differentiated among clients and professionals in the field. Additionally, the following questions were assessed due to research indicating that frequent aggressive behaviors resulting in harm could be viewed as a form of self-injury: “During the past 12 months, how many times were you in a physical fight?” and “During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?” For these questions, those respondents who got into fights four or more times in a 12-month period and had to be evaluated by a medical professional were thought to be possibly engaging in self-injurious aggressive behaviors. Correlations were completed on these items in order to justify their grouping as a variable.
The self-injurious behavior questions were correlated at r = .72, p < .001 and coded as self-injurious when participants answered that they had attempted suicide more than four times in one year and/or had injured themselves physically, either requiring outside medical treatment or not requiring medical treatment. Questions regarding physical fighting were combined to form the aggression variable and were significantly correlated at r = .42, p < .01.
Self-injurious aggression was coded based on extremity of engagement in fighting and the resulting personal injury of the participant. As self-injury may manifest itself differently depending on gender and cultural expectations and experiences, extreme aggression that resulted in frequent hospitalization or medical care was considered to be a possible indicator of this alternative behavioral expression (Harris, 1995; McMahon & Watts, 2002). Self-injury has been shown to result in acting in or acting out behaviors as a way of engaging in emotional regulation (Bjärehed, Wängby-Lundh, & Lundh, 2012; Mikolajczak, Petrides, & Hurry, 2009). The way in which one chooses to manifest self-injury or the typology of the non-suicidal self-injurious behavior may present differently for males and females (Heath et al., 2008; Muehlenkamp & Gutierrez, 2007). Thus, both traditional and non-traditional methods for harm were evaluated for this study, as NSSI is sometimes thought to be a suicidal attempt or behavior by clinical professionals wanting to err on the side of caution because those who self-injure also may have co-occurring suicidal ideation. In contrast to the pressure for immediate and safe clinical intervention, however, those who choose to self-injure and those who attempt suicide often have differing attitudes toward life (Muehlenkamp & Gutierrez, 2004). For this study, logic seemed to dictate evaluating frequent suicide attempts that did not result in medical attention as a possible self-injurious behavior. To further evaluate the consideration of frequent suicide attempts (more than four in a year) as possible NSSI, correlations were conducted between the NSSI variable and items stating, “During the past 12 months, did you make a plan about how you would attempt suicide?” and “During the past 12 months, did you ever seriously consider suicide?” In the 2013 sample, the NSSI variable was significantly correlated with both items at p < .001, with correlations of r = .241 and .218 respectively. Therefore, in the 2013 data set, there was indication that as the attempts increased the participant was more likely to state that they had seriously considered suicide or made a plan in the past year. However, the correlation was low, accounting for only 24 and 22% of participants who stated they had attempted four or more times in a year, a similarity with all other years included in this analysis. Thus, the fact that the majority of those who indicated they attempted suicide four or more times did not indicate they had made plans to commit suicide or had even thought about it seriously points toward an indication that the item also may be measuring NSSI rather than just suicide attempts.
With regard to the demographic variables, gender, ethnicity and depression were all coded dichotomously. Variables were created as described in order to complete a binary logistic regression. This analysis was chosen in order to evaluate the odds that a certain behavior would yield results with regard to the predictor variables used. Of those demographic variables included in the study and coded dichotomously from 2005, 60% identified as Caucasian and 37% identified as being from a marginalized or underrepresented group (e.g., Black/African American, Hispanic, multiple heritage). The remainder did not identify their ethnicity. With regard to gender or biological sex, 49% of the sample indicated they were female while 50% of the sample indicated they were male. The remainder did not respond to the item for male or female identification. Concerning age, 37% of the sample indicated they were 15 or younger and 63% of the sample was older than 15. All of the participants sampled were in grades 9–12. Demographic statistics were similar across each year of analysis.
Separate analyses were conducted for each year of the YRBS included in this review. Trends were assessed and will be discussed following the presentation of results. Binary logistic regressions were completed to determine predictors for both possible non-suicidal self-injurious behavior and potentially self-injurious aggressive behaviors. Categorical contrast baselines were set for: Caucasian, male, age less than 15, reports of no feelings of hopelessness, and no self-injurious aggression.
YRBS 2005 Analysis
Using self-injurious behavior as an outcome variable and gender, age, ethnicity, extreme aggression and depression as covariates predictor variables, a binary logistic regression was completed on the available data set to analyze the goodness of fit. The result was Nagelkerke R2 = .240 which indicated that the variables included in the model accounted for 24% of the variance. The Hosmer and Lemeshow test used for the logistic regression was not significant (χ2 = 10.16, p = .180), indicating that the predicted probabilities match the observed probabilities. These results show a probability that it is three times more likely that those engaging in extreme self-injurious aggression also will engage in self-injurious behaviors and 11 times more likely for those who are depressed to engage in self-injurious behaviors controlling for all other predictor variables (see Table 1). Age and race did not seem to play a significant role in predicting self-injurious behavior, as both age groups (early adolescents and late adolescents) were just as likely to engage in self-injury. In addition, those from different ethnic backgrounds were just as likely to engage in self-injury when controlling for all other factors. Males were half as likely as females to engage in self-injury. However, males were three times as likely to engage in extreme aggression while those who were reportedly depressed were twice as likely to engage in possible self-injurious aggressive behavior (see Table 2).
YRBS 2009 Analysis
In Table 3, the regression for self-injurious behavior is presented. Given the base rates of the two coded options, 83% of the sample choose not to involve themselves in possible self-injurious aggressive behaviors (intentional fighting resulting in injury); therefore, the best predictive strategy is to assume that, for every case, the subject will choose not to participate in fighting behavior that would likely result in injury requiring medical attention. In essence, the odds of someone engaging in aggressive self-injury are approximately 20% (ExpB = .205). In testing the predictive model of age, gender, race, depression and likelihood to engage in individual self-injury, results indicate that the model was significantly predictive at Χ2 = 984.4, p < .001. The Nagelkerke R2 = .110 is an indication that this model would only account for 11% of the variance in predicting self-injurious aggressive behaviors (intentionally fighting to result in injury). After adding the predictive model, 83% of cases were correctly classified, as opposed to an 80% classification rate prior to the addition of variables to the predictive model. The Hosmer and Lemeshow test was not significant (χ2 = 18.83, p > .001), indicating that the predicted probabilities match the observed probabilities. According to the predictive model, if the participant were female, she would be .326 as likely to engage in aggressive self-injurious behavior as compared to males. A Wald Test was used to examine the true value of the parameter based on the sample and all were found to be significant at < .001.
YRBS 2011 Analysis
For the 2011 sample population, 1,300 participants indicated engaging in physical fights four or more times in a year, resulting in the need for medical attention more than once, which fit the criteria for self-injurious aggression (approximately 8% of those surveyed; self-injurious aggression variable). Of those included in analysis, 201 participants indicated that they had attempted suicide four or more times, attempts that did not require medical attention (NSSI variable). Of those students responding, over 4,000 (approximately 29%) indicated feeling sad or hopeless every day for 2 weeks or more in a row during the past year. Feeling sad or hopeless had a weak negative correlation with the NSSI variable with r = -.146, p < .001. Similarly, feeling sad or hopeless had a weak negative correlation with self-injurious aggressive behaviors with r = -.097, p < .001. NSSI and self-injurious aggression had a significant weak positive correlation with r = .195, p < .001. Of those responding to the 2011 YRBS, 7,574 indicated they were Caucasian and 1,629 indicated they were younger than 15 years old.
The binary regressive model for the 2011 data indicates a resultant X2 (4) = 370.27, p < .001. The Nagelkerke R2 = .241 indicates that this model would only account for approximately 24% of the variance in predicting self-injurious behaviors as defined by items 27 and 28 of the YRBS. Of those surveyed, 69.3% were included in analysis. The Hosmer and Lemeshow test was not significant (χ2 = 2.39, p = .935), indicating that the predicted probabilities match the observed probabilities. Wald statistics are significant at p < .001 for the item indicating possible depression, age and the variable assessing possible aggressive self-injury (engaging in numerous physical fights). Wald statistics for race were approaching significance at p = .089; however, age and gender were not significant. Therefore, these demographic variables were likely not contributing significantly to the prediction of NSSI as defined in this study.
Of those participants who identified as possibly engaging in non-suicidal self-injurious behaviors, 98.5% of cases were correctly classified by the model. The classification of cases was not changed when the variables of non-suicidal aggression, depression, age, gender and race were included. The calculated r statistic for non-suicidal aggression was .30, and .24 for the depression variable, indicating that both likely accounted for 54% of the predictive power of the model. The demographic variables could not be calculated due to their low contribution to the predictive model. While z2 was significant for age, the Wald statistic itself was not large enough to calculate a standard analogue of r.
It is important to note that the lower end of the confidence interval for all variables included in the model was less than one, with the exception of the item variable measuring depressive symptoms. This finding is indicative of the likelihood that as non-suicidal aggressive behaviors increase, so too will the possibility for NSSI; however, this relational direction may not be true for all cases occurring within the 95% confidence interval. Nevertheless, we can be more confident in the relationship between indications of non-suicidal self-injurious behaviors (as defined by this study) and the depressive symptoms measured through item 24 of the YRBS.
The Hosmer and Lemeshow’s measure of R2 is .24, indicating a moderate effect size. With regard to probability analysis of the significant variables, it should be noted that if a participant were feeling sad or hopeless, they would be 9.47 times more likely to engage in non-suicidal self-injurious behaviors as defined by this study. If a subject were engaging in multiple fights that resulted in injury, the participant would be 9.317 times more likely to engage in multiple “suicide” attempts that did not result in the need for medical attention. Finally, if a participant was younger than age 15 at the time of this survey, the subject was almost twice as likely to engage in non-suicidal self-injurious behavior (Table 4). Probabilities for binary regression of self-injurious aggression with regard to sex and depressive symptoms can be found in Table 5.
YRBS 2013 Analysis
For this sample population, 872 participants indicated that they engaged in physical fights four or more times in a year, resulting in the need for medical attention more than once. Of those students responding, over 4,000 indicated feeling sad or hopeless every day for 2 weeks or more in a row during the past year, and 177 participants indicated that they attempted suicide four or more times but did not require medical attention for those attempts (conceptualized as possible non-suicidal self-injurious behavior). Of those indicating their ethnicity, 6,416 participants indicated that they were Caucasian. The binary regressive model for the 2013 data indicates a resultant X2 (5) = 295.731, p < .001. As indicated in table 6, the Nagelkerke R2 = .222, which indicates that this model would only account for approximately 22% of the variance in predicting self-injurious behaviors as defined by items 27 and 28 of the YRBS. The Hosmer and Lemeshow test was not significant (χ2 (7) = 8.281, p = .308+), indicating that the predicted probabilities match the observed probabilities. Wald statistics are significant at p < .001 for the item indicating possible depression and the variable assessing possible aggressive self-injury (engaging in numerous physical fights). Wald statistics for race, age and gender were not significant; therefore, these demographic variables are not making a statistically significant contribution to the prediction of NSSI.
As indicated in tables 6 and 7, of those participants who identified as possibly engaging in non-suicidal self-injurious behaviors, 98.7% of cases were correctly classified by the model. The classification of cases was not changed when the variables of non-suicidal aggression, depression, age, gender and race were included. Calculated r for non-suicidal aggression was .32, and .22 for the depression variable, indicating that both likely accounted for 54% of the predictive power of the model. The demographic variables could not be calculated due to their low contribution to the predictive model. It is important to note that the lower end of the confidence interval for variables not significantly contributing to the model was less than one.
In completing this analysis, it is evident that further study is needed in the area of self-injury with regard to outward expression in the form of extremely aggressive behaviors, prevalence among differing ethnic groups and prevalence in the male population. Currently, most research is focused on adolescent Caucasian females, indicating that self-injury may be more prevalent among females and those of Caucasian decent (Whitlock, 2010). Data from the current study indicates that perhaps males and other ethnic groups also are engaging in this destructive coping mechanism, perhaps in differing ways than are being focused on by current conceptual and empirical works. Researchers (Whitlock, Eckenrode, & Silverman, 2006; Matsumoto et al., 2005) indicate that males are more likely to injure areas of the body that are more sensitive when compared to females and to use more severe methods to self-injure. Male self-injurers show injuries to the chest, face, or genitals and the injuries sustained often have more long-term repercussions than those of females who tend to self-injure arms and legs. Males also tend to burn themselves and use hitting and punching type behaviors, whereas females tend to cut (Sornberger, Heath, Toste, & McLouth, 2012). The results of this analysis is consistent with the literature that indicates self-hitting or physically aggressive behaviors resulting in injury is a more typical typology of self-injurious behaviors for adolescent males (Izutsu et al., 2006). By studying a variety of populations, the definition of self-injury can be extended in order to clinically expand other, less damaging ways of coping with extreme emotional discord. Future research is needed concerning self-injury in adolescent males as a singular group as well as studying both males and females with ethnicity and cultural identity as variables.
Expanding the definition of self-injury to include frequent aggressive behaviors that result in harm to the self may be prudent. For instance, Harris (1995) evaluated 363 Hispanic and Caucasian university students with regard to endorsement of aggressive behaviors. He found that males, in general, were more likely to endorse fighting, and Hispanic males were more likely to endorse aggressive behaviors. Harris theorized that this endorsement might translate to emotional regulation factors. Nock (2009) also stated that the majority of current studies on self-injury have not addressed culture and gender issues when discussing self-injury and would, at times, exclusively focus on samples of Caucasian women. He indicated that this approach could conceivably lead to issues in fully evaluating the legal and ethical ramifications of self-injury. Nock’s criticism of not enough research to evaluate the self-injurious prevalence in different settings, age groups, cultures, and with men underlines the need for more investigation. Limited studies have also examined the differences between race, ethnicity and culture among those that engage in self-injurious behavior (Yates, Tracy, & Luthar, 2008). Gratz et al. (2012) found that reporting rates were higher for Caucasian girls as opposed to Caucasian boys, and higher for African American boys as opposed to African American girls. Such findings provide evidence to support the idea that racial and ethnic backgrounds moderate the gender differences in the rates of self-injury. Results from the YRBS provide further evidence that this is indeed an issue that spans culture and gender domains. Research that expands to fully include gender, racial, cultural and age differences is certainly warranted.
If regular harm-to-self aggressive behaviors were included in the definition of self-injury, assessment practices as well as mental health treatment would benefit. Currently, treatments for self-injury include approaches consistent with dialectical behavioral therapy (DBT) and cognitive-behavioral therapy (CBT), as well as interventions associated with each approach including mindfulness, regulating emotions, distress tolerance, and thought stopping (Trepal & Wester, 2007). However, if intersections of gender and culture are to be considered, it is important that a broader holistic approach to the conceptualization and treatment of self-injury be taken. For example, while CBT can serve to address immediate behavioral concerns and provide alternative coping mechanisms for clients as they process the meaning of their behaviors, treatment for the underlying issue is suggested in order to ensure long-term success. Therefore, for any clinical treatment to be optimally helpful and globally applicable, having useful, relevant research data is a must.
Limitations, Implications and Future Research
The limitations of this study are noted throughout, including a lack of clear consensus among practitioners on how to diagnose and treat self-injury. There is a lack of understanding of how self-injurious behaviors are connected to suicidal intent. Clinicians will diagnose suicidal intent out of fear that the injury could result in unintentional death, which ignores the intention of the act (McAllister, 2003; Trepal & Wester, 2007). By further examining self-injury and the measures that exist, the differences can be more clearly defined so practitioners clearly assess for self-injury. The reporting rates on self-injury are difficult to clearly identify and define due to confusions, including little information regarding culture, ethnicity and gender differences. Measures like the YRBS are beneficial, yet lump together the behaviors and are conducted often. This study attempted to further examine the YRBS responses in hopes to show the importance of differentiation between self-injury and suicide intent among various ethnicities, cultures and genders.
Previous research has shown that when underlying issues related to trauma, depression or other related stressors are not addressed, self-injurious behaviors are likely to reoccur later in life even after they have ceased for a number of years (Alderman, 1997; Conaghan & Davidson, 2002; Walsh, 2006). If other presenting behaviors, such as self-injurious aggression, are not recognized as a similar coping mechanism or way of emotionally regulating distressing feelings, appropriate diagnosis and treatment might be elusive, time-consuming and expensive. Therapeutic interventions need to match the client’s presenting concerns and the underlying purpose driving the behavior. The possible cultural and social context involved in the client’s internal perspectives on behavioral choices and subsequent actions might be useful to evaluate. This would allow for space to create a greater sense of self-awareness and thus provide an increased likelihood that the client will be able to regulate or cope with their distressing emotions in a useful and self-empowering way. Feminist, Adlerian, and narrative interventions could be used to help facilitate this process, as they are each grounded in creating awareness of societal influences with regard to one’s personal process, purpose, and self-perceptions (McAllister, 2001; Sweeney, 2009; Worell & Remer, 2003). Mental health counselors may want to evaluate how their current theoretical orientation can help them conceptualize self-injury in productive and useful ways to empower the client toward gaining a greater sense of self-awareness and openness to treatment. Interventions from a variety of counseling perspectives offer clinicians more treatment choices, and more treatment choices translate into greater success in addressing a client’s problem. Research that includes the whole picture of self-injurious behavior provides the most benefit for successful clinical practice.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Kelly Emelianchik-Key, NCC, is an Assistant Professor at Florida Atlantic University. Rebekah J. Byrd, NCC, is an Assistant Professor at East Tennessee State University. Amanda C. La Guardia, NCC, is an Assistant Professor at Sam Houston State University. Correspondence can be addressed to Kelly Emelianchik-Key, Department of Counselor Education, 777 Glades Road, Building 47, Room 458, Boca Raton, FL 33431, firstname.lastname@example.org.