Non-suicidal self injury (NSSI) is the professional name for a number of forms of self-injury. Self-injury is a very common mental and physical health issue affecting many populations, but especially young people and trauma survivors.
Types of self-injury include:
Embedding objects under the skin
Interfering with wound healing
Research by Catledge, Scharer, & Fuller (2012) shows that people who self-injure tend to use multiple methods of self-injuring.
Non-suicidal self injury clearly differentiates these actions from those with suicidal attempts but previous terminology including self-harm and deliberate self-harm (DSH) was less clear on this and so they are not the preferred terms.
Prevalence of Non-Suicidal Self Injury
The prevalence of non-suicidal self injury is estimated at approximately 6% of all American adults (Muehlenkamp, Claes, Havertape, & Plener, 2012). On the ONTX service, approximately 20% of the mental health issues reported by visitors involve non-suicidal self injury. (MacDonald, 2016)
Females are slightly more likely to self-injure than males. (Hawton, 2002)
Causes of Non-Suicidal Self Injury
There are a variety of reasons that people choose to engage in non-suicidal self-injury. The following list is based on the outcomes listed in Rodav, Levy & Hamdan (2014):
Bonding with others
Flashbacks or traumatic memories
Provide an internal sense of control
Reduce/eliminate negative emotions
Seek support from others
To feel something while numb
Hawton, et. al. (2002) conducted a survey of English adolescents and found differing risk factors for self-injury in males and females. Males were more likely to self-injure if they had suicidal behaviour in friends or family members, used drugs or had lower self-esteem. Females were more likely to self-injure if friends or family members had self-injured, if they used drugs, were impulsive, or had depression, anxiety or low self-esteem.
Impact of Non-Suicidal Self Injury
Non-suicidal self injury has been associated with a number of negative impacts, most notably an increase in suicidal behaviour (Halicka & Kiejna, 2015). Often-times people with borderline personality will have a comorbid diagnosis of non-suicidal self injury; people holding both diagnoses tend to engage in more severe and more frequent self-harm (Turner, et. al., 2015)
Self-injury can decrease self-esteem and cause individuals difficulty in interpersonal relationships, employment and other areas of their life.
Assessing Non-Suicidal Self Injury
There are a number of assessment tools used to assess self injury including the Non-Suicidal Self Injury Assessment Tool (NSSI-AT) by Whitlock, Exner-Cortens & Purington (2007), the Self-Harm Inventory (Sansone & Sansone, 2010) or the Deliberate Self-Harm Inventory by Gratz (2010).
Treatment of Non-Suicidal Self Injury
There are a variety of suggested treatments for non-suicidal self injury. Treatments that have shown themselves effective according to Gonzales (2013) include:
Cognitive Behaviour Therapy (CBT). CBT focuses on examining your thoughts, feelings and beliefs when you feel like self-injuring to help you figure out the trigger points and automatic thoughts leading to self-harm. You can then perform thought-stopping activities and coping strategies (see below) to help you cope. CBT was found to be as effective as treatment-as-usual.
Dialectical Behaviour Therapy (DBT). DBT is an extension of CBT that was originally developed to help individuals with borderline personality disorder (BPD), also called emotional dysregulation disorder to cope. DBT extends CBT by including mindfulness, meditation and other activities designed to replace thought stopping. DBT was found to be as effective as treatment-as-usual.
Therapeutic and Psychosocial Assessment. Therapeutic and psychosocial assessments are tools that can be used by mental health clinicians or ER physicians to help understand when and why the person cuts. Therapeutic assessments were shown to increase the rate of followups while psychosocial assessments were shown to decrease the incidence of future self-harm.
Making Meaning. Making meaning refers to strategies to determine what self-injury means for that particular person. Each person who cuts, burns or embeds gets something out of that particular activity, and knowing more about what it is. Making meaning was identified as being helpful by clients, though there is little research evidence confirming this.
In crisis situations or where people feel like they’re not going to be able to keep themselves from self-injuring, it’s important that they have a variety of coping strategies in mind. Coping strategies must be interpreted based on the frame of reference of the self-injuring person. What do they get out of the activity?
Examples of some coping strategies based on what you’re feeling right now are here. Additional strategies may be found here and here.
MacDonald, D.K. (2016) ONTX Program Tracking Report, Unpublished raw data.
Muehlenkamp J.J., Claes, L., Havertape, L. & Plener, P.L. (2012) International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health. 6(10). doi: 10.1186/1753-2000-6-10.
Rodav, O., Levy, S., & Hamdan, S. (2014). Original article: Clinical characteristics and functions of non-suicide self-injury in youth.European Psychiatry, 29503-508. doi:10.1016/j.europsy.2014.02.008
Turner, B. J., Dixon-Gordon, K. L., Austin, S. B., Rodriguez, M. A., Zachary Rosenthal, M., & Chapman, A. L. (2015). Non-suicidal self-injury with and without borderline personality disorder: Differences in self-injury and diagnostic comorbidity. Psychiatry Research, 23028-35. doi:10.1016/j.psychres.2015.07.058
Means restriction is a technique for preventing suicide that involves restricting or preventing access to the tools used to attempt suicide. This can be things like pills (for overdosing), firearms (for shooting), or railways (for jumping.)
Some suicide methods have much higher lethality or chance of causing death than others. For instance, while 85% of firearm suicides results in death, only about 2% of overdoses do. Hangings are approximately 70% (Vyrostek, Annest, & Ryan, 2004).
There is a myth that if we limit one suicide method (like removing firearms from the home), that someone will simply use another suicide method. While it’s true that not all suicide methods exist in all countries and suicides still occur, suicide method restriction does not generally lead to method substitution during that time-limited suicidal crisis.
Support for Means Restrictions
The idea of means restriction (and its connection to means substitution) was first explored in the 1970s and 80s with the change from toxic coal gas to far less toxic natural gas in Great Britain. It was noted at that time that there was no displacement or substitution of suicide method. This was summarized by Clarke (1989).
Daigle (2005) reviewed a number of studies on means restriction and suggested two primary reasons for the reduction in suicide risk associated with restricting means:
Individuals plan their suicide carefully, including becoming attached to specific methods. By restricting access to those methods people are less attached to the idea of dying by suicide at all
Suicidal crises are often short lived periods of intense acute risk. By limiting the most lethal methods people are forced to either delay their suicide plan or switch to a less lethal method, which will either provide time for the suicidal crisis to pass or (in the event of a suicide attempt carried out) time to be rescued
The literature supporting means restriction and it’s relationship to means substitution is reviewed below based on common suicide methods, which are considered high-lethality methods and therefore most affected by means restriction.
Anestis & Anestis (2015) examined the impact of four firearm-related laws: waiting periods to receive one, universal background checks, gun locks, and open carrying regulations on their impact of the suicide rate. Their research found that firearm suicides were reduced when each was implemented and background checks, gun locks and open carrying regulations also reduced the overall suicide rate.
This pattern, stricter firearm laws leading to lower suicide rates was observed in both England (Gunnell, Middleton, & Frankel, 2000) and Austria. (Kapusta, Etzersdorfer, Krall, & Sonneck, 2007)
Additionally, Wintemute et. al. (1999) found that the rate of suicide among handgun owners is 57x higher than the general population in the first week of ownership (because of people who buy a gun for the specific purpose of suiciding) and 7x higher at the end of the first year. It is likely that a person’s risk of dying by suicide remains elevated as long as someone owns a firearm.
Lukaschek, Baumert, Erazo, & Ladwig (2014) examined railway suicides in Germany over 2 separate periods and found that railway suicides were most common on Mondays and Tuesdays. They note that blue lights in Japan and physical barriers have been helpful in reducing railway suicides, in addition to comprehensive changes introduced by the German Railway Suicide Prevention Project.
The changes implemented included “an awareness programme, media approaches, hotspot analysis….and the introduction of a rule regarding announcements to passengers waiting in station or trains, which requires avoidance of the term ‘suicide’, and an indication that the delay is due to a ‘medical rescue operation underway.'”
Law, Sveticic, & DeLeo (2014) examined the impact on the suicide rate in Australia after the installation of a suicide barrier on the Gateway Bridge in Brisbane. The barrier reduced the suicide rate 53%, while there was no shifting of means onto the nearby Stony Bridge.
Meanwhile in Auckland, New Zealand, a bridge barrier was removed on the Grafton Bridge and then reinstated; a 500% spike in the suicide rate occurred while the bridge barrier was absent. (Beautrais, 2009)
Counseling on Access to Lethal Means (CALM)
The Counseling on Access to Lethal Means (CALM) course provides a thorough exploration of means restriction to enable a worker to understand the theoretical basis for restricting access, but also the practical tools surrounding how, when and why to have the conversation about restricting means. It is particularly focused on youth but can be helpful for all populations.
Anestis, M.D., Anestis, J.C. (2015) Suicide Rates and State Laws Regulating Access and Exposure to Handguns. American Journal of Public Health. 105(10):2049-58. doi: 10.2105/AJPH.2015.302753
Beautrais, A.L., Gibb, S.J., Ferguson, D.M., Horwood, L.J., Larkin, G.L. (2009) Removing bridge barriers stimulates suicides: an unfortunate natural experiment. The Royal Australian and New Zealand College of Psychiatrists.
Clarke, R.V. Crime as OPportunity: A Note on Domestic Gas Suicide in Britain and the Netherlands. British Journal of Criminology, Delinquency and Deviant Social Behaviour, 29:1. 35
Daigle, M.S. (2005) Suicide prevention through means restriction: assessing the risk of substitution. A critical review and synthesis. Journal of Accident Analysis and Prevention. 37(4)625-32.
Gunnell, D., Middleton, N. & Frankel, S. (2000) Method availability and the prevention of suicide—A re-analysis of secular trends in England and Wales 1950–1975. Social Psychiatry and Psychiatric Epidemiology. 35:437–443
Kapusta, N.D., Etzersdorfer, E., Krall, C. & Sonneck, G. (2007) Firearm legislation reform in the European Union: Impact on firearm availability, firearm suicide and homicide rates in Austria. British Journal of Psychiatry. 191:253–257
Law, C.K., Sveticic, J., DeLeo, D. (2014) Restricting access to a suicide hotspot does not shift the problem to another location. An experiment of two river bridges in Brisbane, Australia. Australian and New Zealand Journal of Public Health. 38(2):134-8. doi: 10.1111/1753-6405.12157
Lukaschek, K., Baumert, J., Erazo, N., Ladwig, K.H. (2014). Stable time patterns of railway suicides in Germany: comparative analysis of 7,187 cases across two observation periods (1995-1998; 2005-2008). BMC Public Health. 14(1)
Vyrostek, S.B., Annest, J.L & Ryan, G.W. (2004) Surveillance for fatal and nonfatal injuries–United States, 2001. Morbidity and Mortality Weekly Report (MMWR). 53(SS07);1-57. Accessed electronically from http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5307a1.htm on Jan 23 2016.
Wintemute, G.J., Parham, C.A., Beaumont, J.J., Wright, M., & Drake, C. (1999) Mortality among recent purchasers of handguns. New England Journal of Medicine. 341(21):1583-9