Dr Nicholas Westers There’s still a lot of research going on about non-suicidal self-injury in both adolescents and adults, but what we do know, for the most part, is that individuals who self-injure tend to do so to cope with difficult emotions, to be able to manage what can seem unmanageable to them. And sometimes, young people, adolescents in particular, might accidentally discover effects – positive effects of self-injuring. For instance, they might actually get a scratch or cut that they find relieves some emotional tension. So, it’s this accidental re – discovery of the behaviour that works for them in that moment, that they keep in mind for the next time that they’re emotionally overwhelmed, that they go to because they know it works immediately. There’s immediate reinforcement. And then, there are others who’ll find out through social modelling. Nowadays, most people know what self-injury is. So, a teenager might be struggling with stress or emotions and one of their friends self-injures and may suggest it to them. So, they will try it and if it works for them, they may continue on, and if it doesn’t work for them as a coping strategy, they might just, you know, throw it away. However, we know that many young people may start self-injuring at first for interpersonal reasons and that can actually shift for emotional reasons. So, if they’re influenced by a friend to self-injure and they find that it works for them, they may continue to self-injure, not for interpersonal reasons, but for social reason – for emotional reasons. Another common underlying psychological factor is low self-efficacy. So, if they begun engaging in non-suicidal self-injury and they don’t think that they can stop because it’s too hard to think about or just that isn’t even a possibility in their mind, they likely won’t stop if they don’t think that they can. Or another common underlying psychological factor is self-criticism. We know that adolescents and individuals high in self-criticism demonstrate greater willingness to endure pain for longer periods of time, and even experience improvements in their mood during pain. Whereas those who have lower self-criticism, actually experience improvements in their mood upon the removal of their pain. And another psychological factor is impulsivity, or what we might call negative urgency, which is this sense of impulsivity, particularly in the context of unpleasant emotions, where many people experience a lot – this tension, this build-up and then, suddenly feel like this is an impulsive decision to self-injury. But what we know from research is that we can actually find, hours prior to the act of self-injury, this build-up of emotions, of a stress, that reaches a threshold that subjectively feels like it’s out of the blue, impulsive, but we know that we could’ve predicted it well in advance. So, we know that people that self-injure aren’t necessarily any more impulsive than those who don’t self-injure. It’s just that when they have the urge to self-injure, it feels more impulsive and they give in, as opposed to realising that many times, we could look at red flags or vulnerability factors and build-up of unpleasant emotion hours beforehand [pause]. Nock and Prinstein’s four-factor model offers a simple, yet comprehensive, understanding of motives for why someone might self-injure, based in principles of operant conditioning. So, non-suicidal self-injury can serve any combination of four primary functions, we find, that can be categorised under intrapersonal emotional reasons or interpersonal social regions. First, the most common function or reason for self-injuring is for emotional negative reinforcement reasons, where self-injuring helps get rid of feelings and thereby, reinforces the likelihood of using self-injury again in the future, and this is immediate. Typically, when someone self-injures, they get rid of this emotional tension or unpleasant feeling, and it goes away. A second function is for emotional positive reinforcement and where self-injury brings about physical and emotional sensations when someone who may feel numb or empty, where they would rather feel pain than nothing at all, and here, the purpose is to feel something, even if it’s pain. A third function is for social positive reinforcement where self-injuring helps communicate and get a need met or activate resources in the community, what some may call self-injuring to get attention. Yet, it is one of the least commonly endorsed reasons for self-injuring. And a fourth common function is for social negative reinforcement, which is self-injuring in a way that serves to avoid something unpleasant or to get out of an unwanted situation, such as self-injuring at school in order to be sent home to avoid school, or to – self-injuring to avoid punishment. And regarding treatment planning, we typically want to understand what it does for the person so that we can explore healthier alternative coping strategies that serve the same or similar function. But we do need to recognise that self-injury results typically in immediate reinforcement, meaning it works right away or very quickly, whereas alternative strategies often take time. So, if someone self-injures as a way to get rid of unpleasant emotions, we may suggest exercising or journalling, for instance. A lot of students, a lot of adolescents, like to write, but that takes a lot of time to formulate one’s thoughts, write it out on paper, express the feelings, whereas self-injury works immediately. In general, it helps to focus on building healthy coping strategies, so that unhealthy coping strategies, like non-suicidal self-injury, is no longer needed. So, we don’t want to so – focus so much on the behaviour as much as the function that it serves in building healthier strategies for coping that serve that same function [pause]. Some of the most common risk factors for engaging in non-suicidal self-injury is emotion dysregulation, so in self-injuring to regulate those emotions. Bullying, both as perpetrator and victim, and peer victimisation are risk factors for self-injury, especially among younger adolescents, other adverse childhood experiences, like early childhood maltreatment, including physical/sexual abuse, physical and emotional neglect. And meta-analyses actually revealed that emotional abuse is a stronger risk factor for non-suicidal self-injury above and beyond other forms of early childhood maltreatment, like physical and sexual abuse. Poor body regard and body image, as well as disordered eating and low self-esteem, are risk factors for engaging in self-injury. Self-criticism is – especially when someone internalises the criticism of someone else, so parental criticism and the internalisation of that criticism, so that it becomes self-criticism, we know is a risk factor for engaging in non-suicidal self-injury, as well as suicidal thoughts and behaviours. We know that, typically, suicidal thoughts occur prior to engaging in non-suicidal self-injury chronologically and then, months or years later, someone may consider attempting suicide and actually attempt suicide. So, suicidal thoughts are a risk factor for engaging in non-suicidal self-injury. Diagnoses of depression, anxiety or cluster B personality disorders, particularly borderline personality disorder, is a risk factor for engaging in non-suicidal self-injury, but just because someone self-injures does not mean that they have borderline personality disorder or even features of borderline personality disorder. In fact, one study of adolescents looked at NSSI disorder, which is a proposed diagnosis for further study in the DSM-5, and they found that the overlap between NSSI disorder and borderline personality disorder was not significantly greater than the overlap of other diagnoses and borderline personality disorder. For instance, 52% of adolescents who met criteria for NSSI disorder also met criteria for borderline personality disorder, but 52% of those who met criteria for a mood disorder also met criteria for borderline personality disorder, and 48% who met criteria for an anxiety disorder also met criteria for borderline personality disorder. Yet, we don’t say that someone who has depression or anxiety has features of borderline personality disorder. Even though adolescents with borderline personality disorder have a significantly greater odds of being diagnosed with NSSI disorder than those without borderline personality disorder, they have even greater odds of being diagnosed with a mood or anxiety disorder. Protective factors, there’s less research that shows what may be protective against non-suicidal self-injury. We know that emotional acceptance and the willingness to tolerate distress and be able to regulate emotions is a protective factor. But when it comes to protecting against non-suicidal self-injury in relationships, having a strong sense of identity and feeling appreciated is more important in relationships with friends than with parents. However, we know that parents are one of the greatest protective factors for many mental health disorders and conditions, including non-suicidal self-injury. Researchers, including some colleagues of mine and myself, found that having a strong connection to parents is more protective against non-suicidal self-injury than having a strong connection to friends, regardless of the strong sense of identity or even feeling appreciated [pause]. A lot of parents and professionals want to blame social media and online communities for a lot of problems in today’s society and granted, there is a lot of risk factors involved. However, there’s a lot of positive influences online. For instance, many young people who self-injure go online to disclose, as a way of testing the waters, disclosing their self-injury to see how people might respond and determine if they want to disclose it to friends and family in person. Then, if it’s a positive experience, they may decide to disclose to their parents and family and hope for a positive experience, and being online helps them to also feel connected to others and less socially isolated and lonely with their self-injury. So, they may get peer supports. There are positive influences of being in online communities, but there are also negative influences, where someone may share photos or images. We know from research that showing images online, on social media, of wounds and methods of self-injury can actually trigger, in vulnerable individuals who are already self-injuring, they may then experience urges to self-injure. And if they’re trying to recover from self-injuring and stop self-injuring, they actually might go back to self-injure. So, it may be triggering, that’s one risk factor, learning new strategies of self-injuring and ways to hide it is another, and we know that many times, online communities don’t focus on positive stories of recovery, including in the news media. So, they may feel like that they’re alone in this and there’s – recovery is not possible. But we recognise that there is research showing positive influence, as well, and so, we actually developed and wrote media guidelines for the responsible reporting and depicting of non-suicidal self-injury in the media, including in the news and traditional forms of media, like music and movies and television, to be able to responsibly help and provide these communities of support for those who self-injure [pause]. Non-suicidal self-injury is nearly equally prevalent among adolescents across the globe, with only slight variations, depending on geographic and cultural contexts, but there are cultural factors that influence the way that the behaviour is presented. For example, adolescents in non-Western countries are more likely to engage in non-suicidal self-injury for interpersonal social reasons. Whereas adolescents from Western countries are more likely to engage in non-suicidal self-injury for intrapersonal emotional reasons. Many indigenous groups also have more holistic views of wellbeing and may use broader definitions of non-suicidal self-injury, such as considering intentional damage to one’s spirituality as a form of self-injury. Distancing oneself from God may be one form of spiritual self-injury, or as what occur – as what might occur in Pacific Islander cultures, getting a tattoo without cultural connection or meaning could be a form, or another form, of non-suicidal self-injury in that cultural context [pause]. There are typically more negative long-term outcomes for engaging in non-suicidal self-injury, but one positive long-term outcome might be that if someone has struggled with suicidal thoughts, they may have self-injured to avoid acting on those thoughts. So, we call that the anti-suicide function of non-suicidal self-injury. So, maybe years down the road, the one positive outcome is at least they’re still alive. But when it comes to negative outcomes of long-term outcomes of adolescent non-suicidal self-injury, scarring, especially keloid scarring, can be a problem. We know that many times, self-injury can result in scarring and people have mixed relationships with those scars, many times reminding them of the bad times, which can also trigger suicidal thoughts. But sometimes it’s a reminder of recovery and healing and overcoming self-injury, but there’s still – scarring is going to be a long-term outcome for many people who self-injure. Another long-term outcome is loss of friendships. If people who are not sure how to respond to self-injury, they may not want to be around that individual for that much longer. So, it can be taxing on the relationship and so, many times, young people may lose friendships over time because of the self-injury. But, perhaps the most important long-term negative outcome of self-injuring, is never really learning to tolerate unpleasant, difficult emotions, because when someone self-injures, it short-circuits the ability to deal and tolerate with a difficult emotion. Because self-injury works, they never have to experience or tolerate that emotion, but over time, they never learn to cope in a healthy way, especially when there is not an implement or there’s not a way to self-injure, then they may really struggle as a result [pause]. There are actually very few treatments specifically for non-suicidal self-injury, even for adults. So, there’s even fewer available for adolescents and many of these treatments that look at non-suicidal self-injury conflate it with suicidal behaviour, so we don’t know if the intervention is specific to suicidal thoughts and behaviours or non-suicidal self-injury, thoughts and urges and behaviours, or both. So, there are three types in general. One, treatments that target emotion regulation, two, treatments that target differential reinforcement of alternative behaviours, which might consider the cognitive behavioural therapies, and three, digital interventions, online or mobile apps. So, treatments that target emotion dysregulation include dialectical behaviour therapy and emotion regulation therapies. So, DBT, dialectal behaviour therapy, DBT for adults, research has shown significant reductions in self-harm compared to treatment as usual, but like I had mentioned, non-suicidal self-injury and suicide are not typically differentiated. DBT for adolescents, however, has shown – research has shown significant reductions in both non-suicidal self-injury and suicide attempts, but at follow-up, there are no between group differences between the group – the DBT group and the treatment as usual group. Emotion regulation group therapy for adults, which is designed for adult women, typically with borderline personality disorder or characteristics of it, has found significant reductions in non-suicidal self-injury frequency and severity compared to treatment as usual. There has been adaptations for adolescents, so the ERITA, E-R-I-T-A, Emotion Regulation Individual Therapy for Adolescents, has shown promise, as well, as a treatment specifically for adolescent non-suicidal self-injury, with research showing significant reductions in both frequency and number of methods of non-suicidal self-injury in the past month, post-treatment and six month follow-up. Treatments that target differential reinforcement of alternative behaviours that I had mentioned, are typically CBT-oriented. One of the most effective is Treatment for Self-Injurious Behaviors, or TSIB for short. And that was developed primarily for young adults, that likely can be extended toward adolescents and younger people, where research has shown significant reductions in non-suicidal self-injury frequency among those who participated in TSIB. The Cutting Down Programme is an intervention designed specifically for adolescents who self-injure and that’s actually been developed and implemented in Germany, where research is ongoing. But preliminary results have shown that there’s a reduction in non-suicidal self-injury frequency at follow-up, but no between group differences between the intervention group and the treatment as usual group. However, participants in the Cutting Down Programme actually experienced reductions in self-injury frequency more quickly than those in the treatment as usual group. Lastly are the digital interventions for non-suicidal self-injury. One promising area of intervention are what we call single-session interventions, or NS – or SSIs, which are typically 30-minute online interventions that show promise for self-injury – for reducing self-injury. So, there has been a significant decrease, research showing, in self-hatred and a significant increase in a desire to stop self-injury among adolescents participating in a single-session intervention for self-injury, compared to participants in the control group, but there are no changes in the actual behaviour. So, it has promising results, but we know that there is not a good data yet to support single-session interventions for non-suicidal self-injury among adolescents. Another digital intervention that actually can be done on paper is writing. We know, from research, that whether it’s creative writing, journaling or daily diary, just jotting down the – what happened during the day, in a positive way, reduces non-suicidal self-injury frequency among adolescents who self-injure. However, we know that when they stop doing that, when they stop writing, then frequency of self-injury returns to baseline. So, as long as someone is self-injuring and as long as they’re – or I’m sorry, as long as someone is writing and doing it on a daily basis as a healthy coping strategy, there’s good data to show that that can reduce non-suicidal self-injury frequency. So, in summary, we know that interventions specifically for adolescents who engage in non-suicidal self-injury that have shown promise include ERITA, Emotion Regulation Individual Therapy for Adolescents, the Cutting Down Programme in Germany, Treatment for Self-Injurious Behaviors, which is really specifically for young adults, which many are adolescents, and creative expressive journaling and writing. As long as someone, you know, engages in journaling and writing on a daily basis, they’re likely to decrease NSSI frequency.