Here at Sunflower Counseling, MT, we deal with a variety of therapy issues. Here is an example that often comes up in our therapy sessions.
One of the rampant issues counselors face today is non-suicidal self-injury or NSSI. As a counselor for one year outside of Missoula, MT, I am and my colleagues noticed students frequently reported cuts and burns they made on their own bodies.
I found it challenging to understand the reasoning behind this type of self-harm, and thus helping them to not hurt themselves stretched my short-lived experience as a school mental health professional. So I dug in and began to study this problem in the hopes I will be more prepared to support students with this challenging and often misunderstood behavior.
Definition of NSSI
Non-Suicidal Self-Injury (NSSI) is defined as “non-suicidal bodily harm with the absence of suicidal intent,” says De Riggi, Moumne, Heath, & Lewis, in 2017. The DSM-5 classifies NSSI as any premeditated, self-directed actions leading to direct damage of body tissues. This action is often marked in an array of ways, like hitting or punching an object to inflict injury to self, cutting, extreme scratching, skin carving, and interference with wound healing and burning, (according to the DSM-5). Some people may go as far as breaking their bones, injuring their limbs, puncturing an eye or auto-amputation.
The predominant population engaging in NSSI is adolescents with one-third to one-half admitting to some type of self-injury, (*according to Flaherty in 2018). The average age and onset of NSSI is 13 years old. Of all of the forms of NSSI, cutting is the most common. Likewise, cutting is also the most common form of NSSI for adolescent females. Teens frequently report, “the act is not to cause death, but to reduce negative emotions,” (Flaherty, 2018). NSSI may occur suddenly without any history of trauma or psychological problems. It can result from substance use dependence (Flaherty, 2018). NSSI is associated with a range of disorders, including major depressive disorder, dysthymia, posttraumatic stress disorder, substance abuse, eating disorder, and borderline personality disorder (Andover et. al., 2014). Laukkanen et. al. (2013) investigated how the body location of self-cutting may also be an indicator of the severity of the psychological disorder.
Location of NSSI
Laukkanen et. al. (2013) inferred the location of self-cutting indicated the severity of psychiatric problems among adolescent students. In their study they recruited 4,019 students to self-report about NSSI behavior. Among this sample, 440 students reported at one time engaging in self-cutting behavior. Of these 440 students, a majority reported only cutting their upper arms, while 144 students of this sample reported also cutting other parts of their body.
Laukkanen et. al. (2013) concluded mostly adolescent females who had cut elsewhere on their body also had the most severe mental health issues. These included feelings of withdrawal and depression, social problems, depressive symptoms, thought problems, and dissociation. Two-thirds of adolescents who reported cutting on other parts of the body besides the arms also reported suicidal thoughts. The universal report from those who cut was “feeling relief and feeling better after cutting,” (Laukkanen et. al., 2013) Another important conclusion was that many family members of the adolescents actually knew about their loved ones’ cutting behavior, but lacked the ability to help or confront the issue. It was more difficult for many of the adolescents to seek resources and help without the support from their families. Thus it is critical for school mental health professionals to understand NSSI and work to help support the families of these adolescents who are engaging in this behavior.
The Role of School Mental Health Professionals
De Riggi, Moumne, Heath, & Lewis (2017) wrote about guidelines for mental health professionals (MHP) and how they can best support students who struggle with NSSI. De Riggi et. al. (2017) described the unique position MHPs have with helping to identify and respond to this stigmatized behavior as well as to give suggestions of how to implement treatment within schools.
It is important to note, MHPs may hold misconceptions about NSSI, which reinforces the student’s beliefs that no one understands them (De Riggi et. al., 2017). One often under-examined misconception is for MHPs in the school to recognize the variety of methods students use to engage in NSSI such as burning or punching rather than just looking for cutting. One suggestion they made is to not overlook students who use methods other than cutting. Impose a checklist as a screening and list a variety of methods for NSSI.
All school personnel must be diligent in noticing overt warning signs of NSSI such as unexplained cuts, bruises, burns, scratches or scars (De Riggi et. al., 2017). Another sign is wearing inappropriate clothing for the weather such as long sleeves during the warm months (De Riggi et. al., 2017). Students may also refuse to engage in physical activity, which requires a change in clothing (De Riggi et. al., 2017). Also, they may make frequent use of bandages or wrist coverings. Certain expressions sometimes arise that convey self-injurious ideas in their classwork and writing (De Riggi et. al., 2017). Students’ behavior may also be increasingly secretive and display a need for privacy. All of these warning signs can be beneficial for all school staff to be aware of and to report to MHPs as they see fit.
When school personnel and MHP encounter a student engaging in NSSI they must approach with a calm, caring, and compassionate demeanor in order to give the student relief, comfort, and a safe space to talk (De Riggi et. al., 2017). Some people may have strong reactions when learning of this behavior and inadvertently display discomfort, anger, frustration, sadness, helplessness, and possibly repulsion (De Riggi et. al., 2017). These reactions can have a very strong impact on the student and may lead them to not feel safe sharing anything further and closing up. It is also advised not to over-or-underreact to a student’s NSSI (De Riggi et. al., 2017). This may also unintentionally send mixed messages to the student. It is also helpful to use the student’s own language when talking about the self-injury such as “cutting” (De Riggi et. al., 2017). Active listening is also advised. Refrain from advice-giving, storytelling, or sharing information about others who engage in NSSI (De Riggi et. al., 2017).
Lastly, De Riggi et. al. (2017) suggests it is inappropriate to ask a student engaging in NSSI to see their injuries. Revealing them may be experienced as highly aversive for the youth (De Riggi et. al., 2017). It is far more appropriate to consider asking the student if medical attention has been required for their injuries (De Riggi et. al., 2017). It could be damaging to shame such an already vulnerable adolescent. A final component of risk assessment is to inquire about whether anyone else – such as family, friends, school staff, or other mental health professionals – are aware of the youth’s self-injury. This information allows for a more complete understanding of the student’s support system and assists in future monitoring and intervention (De Riggi et. al., 2017).
Treatment Options Available
While many schools may not have the time or resources to provide adequate treatment it is still helpful to understand the options, which have been used for NSSI. Flaherty, (2018) analyzed the common treatments available for NSSI and found four common methods are often used. The literature recommends that mental health providers treating adolescent NSSI should first provide a comprehensive Therapeutic Assessment Brief Intervention. This includes a standard psychosocial history, a risk assessment, and an assessment of goals for treatment (Flaherty, 2018).
Developmental Group Therapy
This first intervention, Developmental Group Therapy, was developed using some of the principals of cognitive behavior therapy, dialectical behavior therapy, social skills training, interpersonal psychotherapy, and group psychotherapy (Flaherty, 2018). The process of Developmental Group Therapy happens in two phases. The first phase is an acute phase, which happens each week and is based on a different theme each session. The six themes used are: relationships, family problems, anger management, depression and self-harm, hopelessness, and negative feelings about the future (Flaherty, 2018). The second phase is the longer phase and starts immediately after completing the acute phase (Flaherty, 2018). This phase focuses on long-term supports and provides a space for participants to participate in a group. It is here that group techniques such as role-playing are implemented.
Mentalization Based Treatment for Adolescents
The definition for “mentalizing” is the “process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes,” (Flaherty, 2018). This option is a manualized and yearlong treatment consisting of 50-minute weekly individual sessions and 50-minute monthly family sessions (Flaherty, 2018). This therapy is a psychodynamic psychotherapeutic program based in attachment theory (Flaherty, 2018). The therapeutic goal is to focus on improving self-control and the ability to regulate affect by increasing both the adolescent’s and the family’s ability to understand behaviors in terms of thoughts and feelings. The main goal of is to help the client understand their feelings and those of others especially in emotionally challenging situations.
This an intervention, and it consists of four phases. The first of which is the assessment phase. In this initial phase, the participant undergoes a mental health psychosocial assessment, which includes a DMS diagnosis, assessment for suicide risk, assessment of mentalizing, assessment of interpersonal functions, medication review, and assessment of drug and alcohol use (Flaherty, 2018). The client also receives a personalized crisis plan consisting of what they can do in a crisis and who to call for help. The next phase is the treatment phase. The individual sessions are meant to be unstructured and to help the participant focus on their current interpersonal experiences and mental state (Flaherty, 2018). After treatment comes the termination phase, which addresses the maintenance of learned techniques and anticipated challenges. Separation issues are addressed (Flaherty, 2018). There is also a phase for family sessions in order to help the family mentalize and understand family conflict (Flaherty, 2018).
Mentalization Based Treatment for Adolescents is designed to strengthen self-control and agency for adolescents who engage in NSSI because of dysregulation and impulse control problems (Flaherty, 2018). NSSI is thought to occur as a response to relationship stress. Self-related negative cognitions are experienced with great intensity, which leads to both intense depression and urgent need for distraction (Flaherty, 2018). This treatment shows the importance of involving the family in relation to improving benefits of treatment.
Dialectical Behavior Therapy for Adolescents
This treatment option is a comprehensive, multi model, outpatient treatment. The adolescent version was adapted from standard adult DBT by Rathus and Miller (2002). The primary focus is to increase behavioral skills and decrease maladaptive behavior. DBT-A works to reduce NSSI by addressing common skill deficits among adolescents with emotional dysregulation and their families (Flaherty, 2018).
DBT-A is delivered through family groups, individual therapy, and telephone consultations. The intervention lasts for 19 weeks with one-hour individual sessions and weekly two-hour multiple family group sessions (Flaherty, 2018). The focus on individual sessions is to create skills that are helpful for real-life situations. The multiple family group sessions teach core mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance (Flaherty, 2018). The telephone consultations happen between sessions and help to reinforce therapeutic goals (Flaherty, 2018). This intervention indicates the effectiveness of the use of psychoeducation by clinicians to reduce NSSI behavior. It also highlights the importance of involving family to improve the benefits of treatment.
Therapeutic Assessment Brief Intervention
This intervention is a 30-minute manualized intervention that is offered immediately after the standard psychological assessment. Therapeutic Assessment Brief Intervention (TABI) works to help identify the target problem, use techniques to enhance motivation to change, and identify postnatal solutions. It concludes with an “understanding letter” shared with the youth and family that summarizes the agreed on strategies (Flaherty, 2018).
TABI is given in two phases. The first phase has the clinician assess risk and conduct a psychological history for about an hour. The clinician then immediately reviews the assessment (Flaherty, 2018). The second phase takes about 30 minute to complete. The clinician and participant construct a diagram highlighting reciprocal roles and maladaptive behaviors (Flaherty, 2018). The target problems are then identified and an evaluation of the client’s stage of motivation for change is determined (Flaherty, 2018). Lastly, potential exit strategies to break away from the maladaptive behaviors are determined (Flaherty, 2018). These exit strategies are included in the understanding letter developed by the therapist and adolescent and is given to the family.
One ethical concern regarding NSSI is the issue of how to determine protocol for parental notification. School MHPs must often weigh legal responsibilities to the school and parent along with the trust and rapport built with the student in crisis (De Riggi et. al., 2017). Some MHPs suggest if a youth is determined low risk for suicide and does not present serious mental health concerns, then NSSI may not require a parental contact (De Riggi et. al., 2017). If the adolescent is believed to be at serious risk to themselves, the school MHP is advised to contact the student’s parents (De Riggi et. al., 2017). Every school district and administration may enact different protocol.
Implications for Practice
There continues to be the need for greater research in this area in order to determine the best course of treatment for adolescents who are experiencing NSSI. According to Andover et. al. (2014), NSSI may be difficult to treat, but people do respond to treatment. It is highly beneficial for MHPs and school personnel to be trained in understanding and treating NSSI when confronting a student possibly dealing with this issue.
As a counselor interested in working in the schools I feel a greater need to not only develop my own skills with supporting students who engage in NSSI, but to also create greater awareness for parents, school staff, and the school community. It is through this awareness and education that many students will not feel so ashamed and frightened to reach out and seek the help and support they deserve.
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