A clinician-researcher’s approach
Reprinted from the "Young People: Self-Injury" issue of Visions Journal, 2017, 13 (2), p. 5
My journey to better understanding self-injury in young people began after I completed my residency in psychiatry in the early 90s. I became the director of a new partial-hospitalization program for adolescents at the Children’s Hospital of Eastern Ontario (CHEO). By the late 90s, nearly 40% of the program’s youth were presenting with nonsuicidal self-injury (NSSI).
We offered a range of therapies to treat emotional and behavioural issues, including early-onset mental health disorders. Our approach took a developmental perspective and considered the interaction of biological, individual and social factors. When a youth arrived having recently self-injured, we would discuss with the youth, or the youth and the family, what might be triggers or contributors for the NSSI. We often came up with a range of possibilities. At times, having a number of perspectives made it challenging to consider the approach best suited to the youth.
I had access to a trial computer program to use for structured symptom review. The youth readily answered questions about their mental health on the computer. It was helpful to use their answers as “talking points” with the youth and the team, to consider conditions such as depression and anxiety, mood swings, and attentional and behaviourial struggles, which may be a biological, individual and/or environmentally based contributor to their self-injuring behaviour.
One of the things described by a number of youth was that their self-injuring “worked better” than anything I could provide in the short term in terms of “relief.” When I looked for research on the subject, however, I found there had been little published on youth that pertained to what they were describing. We needed to understand a lot more.
With a colleague from the CHEO Research Institute, I developed a questionnaire designed to elicit research-based evidence on the subject. The Ottawa Self-Injury Inventory (OSI) asks some key questions, including questions about what motivates a young person to start or continue to self-injure and whether there is an addictive component.
The most common reason for self-injury given by the young people in hospital was the desire to manage difficult emotions, such as a depressed mood, anxiety, anger or frustration. Most youth indicated more than one motivation to self-injure. Some were using NSSI to manage and prevent acting on suicidal thoughts.
A number reported addictive features. Some had to self-injure more often or more severely to achieve the same effect they had achieved previously. Self-injury was interfering with their social, family and/or school life. Some felt that thinking about self-injury or the actions around self-injury had become time-consuming. These responses suggested that self-injury behaviours could, for some, be highly reinforcing, even for those who wanted to stop.
Based on more research by others, we expanded the OSI to include questions on how NSSI could be used to communicate a youth’s distress indirectly to others, for example, “to show how hurt or damaged I am” or “to stop my parents from being angry with me.” We found that social influencing was a function for the behaviour, and for others, it was sensation-seeking.
In Victoria, BC, around 2005, I collaborated with the Centre for Youth and Society at the University of Victoria, completing a population-based survey of nonsuicidal self-harm in youth (ages 14 to 20) in the Greater Victoria area. Of those who self-harmed, approximately one-third reported that they did so more than three times. Lifetime rates of NSSI, specifically, were almost 14%.
Recognizing that rates of NSSI were high in youth and that new research needed to be translated to those working closely with youth, I co-edited with Dr. Nancy Heath, from McGill University, the first evidence-based interdisciplinary text on NSSI in youth. We wanted to reach a readership including school professionals, youth mental health clinicians, those working with families, family physicians and pediatricians.1 This text was the culmination of a personal goal to share as much information as possible to a wide readership and support others in their journey to better understanding this behaviour.
When working with NSSI in young people, here are ten key things I consider:
Use the right term: “nonsuicidal self-injury.” Terms such as “self-harm,” “parasuicide” and “self-mutilation” are too broad or confuse NSSI with suicidal behaviour. They can also be pejorative. Research results that lump together suicidal and non-suicidal behaviours may be confusing.
NSSI is defined as the deliberate destruction of body tissue (for example, self-cutting or self-scratching), without the intent to take one’s life, not socially sanctioned within one’s culture and not for display. When a clear definition is used, more consistent research on the causes of the behaviour and on best treatment practices can occur.
Educate others on your team. Help other caregivers understand that NSSI is not suicidal behaviour per se, but that the two types of behaviour can co-exist. We now know that NSSI can be a precursor to suicidal behaviour. It provides an opportunity to intervene before things potentially worsen.2
Beware misdiagnosis. NSSI in young people does not necessarily indicate borderline personality disorder. Young people who self-injure may be misdiagnosed when other mental health issues like depression, moods swings and anxiety, and concerns about sexual identity, as well as possible family and peer stressors, are significant factors. It is important to consider carefully one’s formulation and/or diagnostic impression. For a review of major mental health issues in young people, see www.learninglinksbc.ca.
Listen more than talk. Most young people are willing to share information about their behaviour when you display “respectful curiosity.”3 Each individual and family has a story; it is important to listen when asking key questions. The OSI questions can be used to encourage discussion about behaviour that the youth might otherwise find difficult to talk about face-to-face: see the Ottawa Self-Injury Inventory under the For Professionals link on the INSYNC website, at insync-group.ca.
Encourage patience and hope. While NSSI prevalence rates appear high in youth, they diminish with age. Cornell researchers report qualitative data that suggest such changes in an individual’s behaviour may be attributable to changes in the individual’s ability to regulate emotion, his or her self-awareness and important relationships with others.4,5
Support the family’s participation. In our health systems, family members can often feel left out of the loop. In my experience, the whole family benefits from an increased understanding of NSSI behaviour and—to start—how to manage crisis situations. When we support families to raise their awareness and understanding, we can see improved outcomes. See insync-group.ca/for-family-and-friends/ and sioutreach.org/learn-self-injury/parents-and-families/ for further information.
Use a sequential, individualized approach. While a number of therapies exist for the treatment of NSSI, evidence-based research regarding outcomes remains inconclusive. Dialectical behaviour therapy, emotional regulation group therapy and manual-assisted cognitive therapy, for example, have shown promise.6 Practitioners should use an approach that best meets the needs of the young people in their specific region/culture. Easy and non-stigmatized access to a service that provides opportunity for assessment and targeted treatment is the ideal scenario. Sometimes, several one-on-one sessions with a counsellor or physician may adequately address a major stressor and set the stage for learning and reinforcing adaptive coping skills and linking with other resources.
Ensure the youth is an active agent in recovery. In my experience, recovery can occur when a youth is open to considering change to his or her behaviour. Motivational interviewing may be a good place to start with those who are contemplating change but remain unsure. A discussion of harm reduction can also help. Check out the motivation-for-change scale in the OSI for a clearer picture of whether the youth is ready to explore recovery approaches and what approaches may work.
The OSI (or the briefer OSI Functions) can be used to assess and map out an individualized recovery approach. The following sites also include helpful assessment and treatment-planning information: www.ncbi.nlm.nih.gov/pmc/articles/PMC4495629 and insync-group.ca/for-professionals.
Be aware and use social media positively with regards to NSSI. The advent of the Internet has introduced a complexity to parenting and to young people’s social environments. The following link provides a helpful summary of the impact of social media and includes recommended guidelines. The Internet and social media are here to stay. We need to support parents and youth to maximize the upside of these new communication forms and minimize the downside. See www.selfinjury.bctr.cornell.edu/perch/resources/the-relationship-between-non-suicidal-self-injury-and-social-media.pdf.
Use the school system. Some school boards are implementing mental health curricula as early as elementary school to help younger children develop a greater awareness of their emotions, improve their communication skills and learn appropriate tools to manage stress. Young brains can be very plastic, and many children can establish these healthy habits. Schools are great places to model and practise emotional regulation and healthy communication. See how your local school system might benefit from these programs: healthyschoolsbc.ca/category/11/positive-mental-health.
The subject of self-injury in youth can provoke a range of emotions and responses. We are challenged with understanding and managing our own reactions while we work with youth and families who courageously share their vulnerabilities with us. As guest editor of Visions, I am privileged to be a part of this broad presentation of perspectives. I encourage Visions readers to reflect on the experiences of these youth and families and the insights of the professionals who work with them.
About the author
Dr. Nixon is a clinical associate professor in the Department of Psychiatry, UBC, and practises child and adolescent psychiatry in Victoria, BC. She has published clinical and population-based research on nonsuicidal self-injury in youth and established a network of Canadian researchers. Dr. Nixon has provided numerous seminars and workshops for parents, schools and community and mental health agencies who are interested in better understanding and supporting self-injuring youth
Nixon, M.K. & Heath, N.L. (2009). Self-injury in youth: The essential guide to assessment and intervention. New York: Routledge.
Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B. & Goodyer, I. (2011). Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). American Journal of Psychiatry, 168(5), 495-501. https://doi.org/10.1176/appi.ajp.2010.10050718.
Walsh, B. (2005). Treating self-injury: A practical guide. New York: Guilford Press.
Nixon, M.K., Cloutier, P. & Jansson, S.M. (2008). Nonsuicidal self-harm in youth: A population-based survey. Canadian Medical Association Journal, 178(3), 306-312. http://www.cmaj.ca/content/178/3/306.full.pdf.
Whitlock, J., Prussien, K. & Pietrusza, C. (2015). Predictors of self-injury cessation and subsequent psychological growth: Results of a probability sample survey of students in eight universities and colleges. Child and Adolescent Psychiatry and Mental Health, 9(19). https://capmh.biomedcentral.com/articles/10.1186/s13034-015-0048-5.
Turner, B., Austin, S. & Chapman, A.L. (2014). Treating nonsuicidal self-injury: A systematic review of psychological and pharmacological interventions. Canadian Journal of Psychiatry, 59(11), 576-585.