Dr Nicholas Westers Non-suicidal self-injury, or NSSI for short, is purposely inflicting injury upon oneself that results in immediate tissue damage. It’s done without suicidal intent. It’s not socially sanctioned, and it’s not for display, so we’re not talking about tattoos, even if someone gives themselves a tattoo. And examples of self-injury, or NSSI, include self-cutting, biting, hitting, severely scratching, burning, and even using an eraser to cause an abrasion in one’s skin. About 18 to 23% of adolescents, throughout the world, report having self-injured at least once, and about six to 7% of children ages six to 12 report having self-injured. So, that’s basically one in five adolescents, and one in 15 children ages six to 12 have self-injured at some point in their lives. So, younger children are more likely to engage in self-hitting and self-scratching, whereas older adolescents or older children and adolescents are more likely to self-injure through cutting, burning, and other methods such as those [pause]. I think it’s important to look at three different things to differentiate between NSSI and suicidal behaviour intent, method and lethality. So, typically with intent in suicide, there’s at least some desire to die, or end one’s consciousness and suffering. For non-suicidal self-injury, the goal is typically to cope with emotions and to feel alive sometimes, and even sometimes avoid acting on suicidal thoughts. For methods and lethality, those who attempt suicide typically choose one method, and if they self-injure, it’s usually different than the method that they use to self-injure, and it’s usually of greater lethality, so using a firearm, asphyxiation, and pills. Whereas those who engage in non-suicidal self-injury, typically use more than one method, but it’s typically less lethal, such as, self-cutting, self-biting, self-burning. And most people who self-injure, when they do, we know from research that those episodes are only accompanied by suicidal thoughts about one to 4% of the time. Most people who engage in non-suicidal self-injury use more than one method, but they’re of low lethality, and typically, and rarely, require medical attention. One common warning sign that a teenager may be self-injuring is taking note of frequent or unexplained bruises, scars, cuts or burns. And if they become defensive when you ask about them, do they offer excuses like, “Oh, my cat scratched me,” or, “I feel on some glass”? Second, take note of what they’re wearing, and when it’s really hot outside and they’re using hoodies to cover maybe their arms, or wearing long pants as opposed to shorts, to cover scars in hot weather. Are they wearing arm warmers across their forearms? Are they resistant to participate in gym class or classes that require them to expose parts of their body that they otherwise might not want to expose because of wounds. And then take note of their behaviour. Are they spending unusual amounts of time in the bathroom? Are their writing assignments have – do they have themes of self-injury, poetry and songs and essays and other creative writing? And do they possess unusually sharp objects? Like the little blades from the plastic pencil sharpeners, rather than it being in the sharpener, have they removed it? Do they have a lighter, even when they don’t smoke? Are they using – or have access and holding possession of razorblades? And are they less social suddenly, and they seem to be more isolated and lonely and sad? One common misconception about self-injury is that it is suicidal behaviour. We know that it is a risk factor for later attempting suicide, but most people who self-injure are not thinking about suicide or even ending their life when they self-injure. But perhaps the most common misperception that I hear is that self-injury is a – an attention seeking method. It’s a way to get attention. And although it is true that some young people self-injure to get attention, it’s actually one of the least commonly endorsed reasons for self-injuring, yet one of the most commonly believed reasons that people give for self-injury. But let’s say that someone does self-injure to get attention. First, can you imagine feeling like the only way you can get attention and care that you need is by intentionally hurting yourself? What must be awry in the environment for someone to have to go to that extent, to get the help and care and focus and attention that they need? Second, if they’re self-injuring to get attention, give them attention. Third, rather than accusing them of self-injuring for attention, consider these, consider thinking about it in this way. One, what are they trying to communicate? Two, what needs are they not getting met? And three, what resources in their environment are they trying to activate? Another common myth of self-injury is that it is a white adolescent female problem. We know that the behaviour traverses race, gender and culture. Boys self-injure, adults self-injure, and those who are not white self-injure. A final misconception of self-injury is that cutting is the only form of self-injury. It is the most common form, but there are other forms that individuals engage in, as well, that are forms of non-suicidal self-injury [pause]. First, and most importantly, always respond with a kind, respectful curiosity, in a lowkey, dispassionate demeanour. Second, if you suspect a teenager is self-injuring, you can simply let them know that you’ve noticed some things, and ask them if they’ve been self-injuring. This is important because we know that just as asking about suicide does not put the idea of suicide in the person’s head, if they haven’t already thought about it, there are also no effects that are similar to non-suicidal self-injury, meaning, it’s okay to ask to about self-injury. It’s not going to put the idea in their head, if they haven’t already thought about it. In fact, it can oftentimes bring relief now that it becomes out in the open. So, when we ask about it, we can take note and say, “I’ve noticed some cuts on your arms recently and they look self-inflicted. I’ve also noticed that you haven’t seemed yourself lately, have you been hurting yourself?” Another example might be, “I’ve noticed you’ve been wearing a hoodie and a jacket and it’s just really hot outside, and I know some students wear long sleeves to hide some marks or bruises or scars that they’ve inflicted upon themself, and I’m wondering if this has been something that you’ve been struggling with?” Third, what may feel urgent to you, may feel commonplace to them. So, recognise that although you just found out about the self-injury, it’s possible they’ve been doing it for a long time, and may not even see it as a problem. Fourth, and relatedly, expecting them to immediate stop may actually not be realistic, especially if they’ve been self-injuring for a long time and if it’s been working for them as a coping strategy. Demanding that they immediately stop the behaviour, although tempting, may actually push the behaviour into greater secrecy and they might hide it from you in continuing – and continue to self-injure. Also, many young people self-injure to punish themselves, and it’s always hard for me to hear about parents and Teachers who punish a student or child for having self-injured, for having punished themselves. They don’t need punishment, they need positive support. Fifth, they may have some scarring from their wounds. They may have a complicated relationship with those scars, and those scars could remind them of bad days in the past, or times that they’ve really struggled, or it might remind them of healing and having overcome self-injury. We can ask them to cover open wounds at home and school, for infection control purposes and not wanting to spread germs or get infections, but this should not be the case for scarring, because that’s a part of the person’s body, the child’s body, over which they have no control at this point. And many times, being able to wear short sleeves or shorts or certain clothing that exhibits the scars is part of the recovery process and helps them to overcome self-injury [pause]. First, adolescents know that the adults in their lives, whether parents or Teachers, are likely not going to approve of the behaviour, so lecturing them is likely not going to be helpful. Instead, to foster open communication, it’s okay to express concern, such as, “It’s really hard for me to know that you’re hurting yourself. I don’t like it that you’re doing this, but I’m here for you, and we’re going to get through this together.” Second, build empathy, by remembering that we’ve all done things that we know are not in our best interest, even you. Third, ask them respectfully curious questions about the behaviour, such as, “I’ve learnt that self – that people self – I’ve learnt that people self-injure for a reason and I’m really invested in learning what it does for you, and why it is that you do that. In what ways does it help you? And what does it do for you?” Fourth, offer to be your child or your student’s coping strategy, someone that they can go to, if they experience an urge to self-injure. Fifth, ask how you can help, rather than immediately locking away the sharps all throughout the house. Ask them if this would actually even help. Make it a collaborative process, rather than a top-down approach where you’re calling the shots. Sixth, redefine success and make room for times that you child may give in to urges to self-injure. Giving into an urge to self-injure doesn’t necessarily reflect failure or going back to square one. In fact, if they’ve gone for a long time without self-injuring and then give into an urge, that sometimes actually demonstrates progress, not going backwards, or taking two steps back and one step forward. Remember, you don’t see the times that they’ve resisted their urges, you only see the times in which they didn’t. Which leads me to my seventh point, acknowledge that if it was easy to stop, they probably already would have by now. Finally, and this is probably the most important point, if your initial response to your child or your student was a negative one and you blew it, own it, take responsibility and do a do-over. Apologise. Apologise to your child, to your student, have a do-over, and respond in a better, more kind, compassionate, respectfully curious way this time. A genuine apology and kind response from you will likely open up communication where it was once shut off [pause]. A school intervention called The Signs of Self-Injury Programme has been developed for schools to decrease stigma and increase help-seeking attitudes among students who self-injure. And although we have found that it doesn’t necessarily decrease the behaviour or increase help-seeking behaviour among those who do self-injure, it does improve attitudes of friends, and getting friends con – their friends who self-injure connected to help. So, there’s a greater positive attitude, and it has served well for that. And we also know that there are school response protocols specifically for non-suicidal self-injury that should be in place instead of, or separate from, suicide protocols. And we don’t want to necessarily do school assemblies or only one topic on non-suicidal self-injury and focus an entire class on that, but it can be – we can talk about healthy coping and unhealthy coping, in terms of a overall wellness programme in a school setting, in which non-suicidal self-injury can be mentioned, as one of the unhealthy ones, to bring attention to it. And, finally, perhaps the best prevention strategy is a good relationship with parents. Having a good healthy relationship with parents is one of the most protective factors against so many mental health difficulties, including non-suicidal self-injury [pause]. There are a number of online resources for parents. My go-to favourites include Self-Injury and Recovery Resources at Cornell, Self-Injury Outreach and Support, or SIOS. For schools, the International Consortium on Self-Injury in Educational Settings, or ICSES, Shedding Light on Self-Injury, based out of Australia. And for parents seeking support, they can use Speak Health. And probably one of my favourites, ‘cause I’m a little biased here, is the Psychology of Self-Injury podcast, which is meant to be a resource for parents, professionals and people with lived experience of self-injury. So a lot of parents may go to there to get quick information on different episodes, and it’s available on most podcast platforms, including Spotify and Apple [pause]. It’s really important to remember that it is not your responsibility to get them to stop, and their inability, or ability, to stop self-injuring is actually not even a reflection of you. I highly recommend that you learn as much as you can about the behaviour, whether reading books or visiting the resources that we just provided, and we know that a healthy – an emotionally healthy parent typically makes a better parent. And so, if you’re really struggling with this, it’s okay to get into therapy yourself, to be able to talk to someone in a confidential way, to help guide you how you can respond to your child. So, therapy, learn as much as you can about the behaviour, and it’s not your responsibility to get them to stop, and it’s not a reflection of you.