Manual 11 Essentials Selfharm Recovery (28280)

Rehab
11 Essentials for Self-

Harm Recovery
Helping Children & Teens
Reclaim Their Lives
Tony Sheppard PsyD, CGP, FAGPA
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Harm Recovery
Helping Children & Teens
Reclaim Their Lives
Tony Sheppard PsyD, CGP, FAGPA
Rehab
ZNM020188
5/15
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46pp
5/15
Rehab
MATERIALS PROVIDED BY
TONY L. SHEPPARD, PsyD, CGP, FAGPA, is a licensed clinical

psychologist with a background that spans community mental
health, residential, inpatient, and private practice settings with
children, youth, and adults. He is the founder and director of
Groupworks, a psychology practice in Louisville, KY specializing
in group therapy with children, adolescents, and their families.
The Groupworks teen program treats youth with emotional
problems, frequently including NSSI, and Dr. Sheppard has led a
number of workshops on NSSI for psychologists, case managers,
educators, and nursing staff. He completed his graduate training
in the School of Professional Psychology at Spalding University
in Louisville. In addition to his clinical work, Dr. Sheppard
teaches group psychotherapy for the program, and Groupworks
serves as a training site for advanced doctoral students.
PESI, Inc. and Tony Sheppard indicate that the content being presented is without bias of any
commercial product or drug. Tony Sheppard is a speaker for PESI and receives compensation.
There is no nonfinancial relationship to disclose.
Materials that are included in this course may include interventions and modalities that are beyond the
authorized practice of mental health professionals. As a licensed professional, you are responsible for
reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of
practice in accordance with and in compliance with your professions standards.
Harm Recovery
Tony L. Sheppard, Psy.D., CGP, FAGPA
What is Non-Suicidal Self-Injury?
o Broad class of behaviors defined by direct,

deliberate, socially unacceptable destruction of
one’s own body tissue without the intent to die.
o Self-injury typically refers to a variety of

behaviors in which an individual intentionally
inflicts harm to his or her body for purposes not
socially recognized or sanctioned and without
suicidal intent
1
o Self-harm
o Deliberate self-
harm
o Self-injurious
behavior
o Self-mutilation
o Cutting
o Self-injury
o Self-Inflicted
Violence
o Skin
o Cutting
o Burning
o Picking
o Biting
o Interfering with wound healing
o Punching oneself or objects
o Inserting objects under the skin
o Hitting Self
o Beating Self
o Head Banging
o Hitting Walls or
Other Hard
Surfaces/Objects
o Having Others
cause injury/pain
o Self-Tattooing &
Piercing
2
o Genital mutilation, amputation, ocular
mutilation, auto-cannibalism
o These forms of self-harm are extremely
rare and typically not seen in outpatient
settings
o Walsh (2006) cites Grossman (2001) in
stating that +/- 80% of people are
psychotic while performing extreme self-
mutilation
o Others at-risk for this:

o Violence prone males
during acute
intoxication
o Transgender males
seeking sex change
o Severe Personality
Disordered Individuals
Population Prevalence Rate Source
Pre-Adolescents 7% Lloyd Richardson (2010)
18-25 Year Olds 13-45% (Lifetime) Rodham & Hawton (2009)
Older Adol/College Age 12-35% (Lifetime) Miller, Rathus & Linehan

(2007)
Adults-Community Sample 6% (Lifetime) Klonsky (2011)
Adults-Clinical Sample 20% (Lifetime) Briere & Gil (1998)
Males 9% Laye-Gindhu & Schonert-

Reichl (2005)
Females 20% Laye-Gindhu & Schonert-

Reichl (2005)
3
o Higher among psychiatric and
incarcerated populations
o More recent studies have shown no
difference in rates among males and
females/Others have shown more NSSI
among females
(Lloyd-Richardson, 2010)
o US Community
Sample of
Adolescents (Laye-
Gindhu & Schonert-
Reichl, 2005)
o NSSI Ideation
was reported by
o 28% of Males
o 53% of
Females
o Klonsky (2007) looked o Walsh & Frost (2005) in

at forms of NSSI Survey of 70
 70-90% engage in Adolescents
Skin Cutting  82.4% Skin Cutting
 21-44% engage in  64.7% Skin Carving
 64.7% Head Banging
Banging or Hitting  61.8% Picking At Scabs
 15-35% engage in  50% Burning
Burning  58.8% Self-Hitting
 52.9% Self-Piercing
(Other than proper
ornamental)
As cited in Walsh, 2012
4
o Childhood Factors
 Sexual Abuse  Poor Affective
 Physical Abuse Quality & Security
 Neglect/Parental with Attachment
Indifference Figures
 Family Violence  Single Parent
 Parental Impulsive Family
Violence  Parental Illness or
 Family Alcohol Disability
Abuse
 Separation & Loss
o Emotional Reactivity
o Emotional Intensity
o Hopelessness
o Loneliness
o Anger
o Risk Taking & Reckless Behavior
o Alcohol Use
o Marijuana Use
o More Negative Emotions
o Social Problem Solving & Communication Deficits
o Socially sanctioned
o Intent is usually not
to do harm
o Tissue damage is
viewed as
meaningful or
enhancing
o Extreme cases CAN
cross the line
o Self-tattooing &
Piercing
5
o Many studies have
suggested that NSSI
begins between ages of
12 & 15
o A 2008 study of college
students found that 41%
began NSSI between
ages of 17 & 20
o Early onset around age 7
o More than 25% start after
age 17
o NSSI can last for weeks, months, or years

o Tends to be cyclical rather than linear
o For those who start during college years,
majority stop within 5 years
o Like any coping strategy, it can be
triggered by stress, distress, changes in
the environment, etc.
o Gender
o Differences in reason and method for NSSI behavior
o Males may use more NSSI behaviors that lead to bruising
o Males may punch objects or other people with the intent to self-harm
o Females more likely to use cutting or scratching
o Race/ethnicity
o Research unclear
o Some studies show more common among Caucasians
o Other studies show similar rates among minority populations
o Sexual Orientation
o Being a member of a sexual minority group may be a risk factor
o Bisexual females particularly at risk
o SES
o No clear differences among higher and lower
Whitlock, 2010
6
o Research is primarily among
clinical populations
o Among clinical populations
o Childhood abuse or
trauma, especially CSA
o Eating Disorders
o Substance Abuse
o PTSD
o Borderline PD
o Anxiety Disorders
o Depression
Nonsuicidal Self-Injury
A. In the last year, the individual has, on 5 or more days, engaged in
intentional self-inflicted damage to the surface of his or her body of
a sort likely to induce bleeding, bruising, or pain (e.g., cutting, burning,
stabbing, hitting, excessive rubbing), with the expectation that the
injury will lead to only minor or moderate physical harm (i.e.,
there is no suicidal intent). Note: The absence of suicidal intent has either been
stated by the individual or can be inferred by the individual’s repeated engagement in a
behavior that the individual knows, or has learned, is not likely to result in death.
B. The individual engages in the self-injurious behavior with one or more
of the following expectations:
1. To obtain relief from a negative feeling or cognitive state.
2. To resolve an interpersonal difficulty.
3. To induce a positive feeling state.
Note: The desired relief or response is experienced during or shortly after the self-injury,
and the individual may display patterns of behavior suggesting a dependence on
repeatedly engaging in it.
American Psychiatric Association, 2013
C. The intentional self-injury is associated with at least one of the

following:
1. Interpersonal difficulties or negative feelings of thoughts,
such as depression, anxiety, tension, anger, generalized distress,
of self-criticism, occurring in the period immediately prior to the
self-injurious act.
2. Prior to engaging in the act, a period of preoccupation with the
intended behavior that is difficult to control.
3. Thinking about self-injury that occurs frequently, even when it
is not acted upon.
D. The behavior is not socially sanctioned (e.g. body piercing,
tattooing, part of a religious or cultural ritual) and is not restricted to
picking a scab or nail biting.
E. The behavior or its consequences cause clinically significant
distress or interference in interpersonal, academic, or other
important areas of functioning.
7
F. The behavior does not occur exclusively during
psychotic episodes, delirium, substance
intoxication, or substance withdrawal. In
individuals with a neurodevelopmental disorder, the
behavior is not part of a pattern of repetitive
stereotypies. The behavior is not better explained by
another mental disorder or medical condition (e.g.
psychotic disorder, autism spectrum disorder,
intellectual disability, Lesch-Nyhan syndrome,
stereotypic movement disorder with self-injury,
trichotillomania [hair-pulling disorder], excoriation
[skin-picking] disorder).
o Constant use of wristbands

o Inappropriate dress for season
o Constant use of wristbands or
something covering the arms
o Unwillingness to participate in
activities which require less
covering of the body
o Frequent bandages
o Heightened signs of anxiety or
depression
o Finding paraphernalia such as
razor blades, lighters, etc.
o Withdrawal
o Negative Self-Statements
What Other Signs Do

You Look for?
What Have You
Seen?
8
o Some adolescents have
elevated rates of
emotional reactivity,
hyper arousal, and
intensity.
o Adolescents who
engage in NSSI may use
avoidant behavior and
decreased emotional
expressivity
o More likely to be bullied
by peers
Peterson et al., 2008
o More likely to report

discomfort with sexual
identity
o One study found an
associate with “Goth”
subculture and NSSI
o Knowledge of self-harm in
peers (social contagion)
o Some websites and chat
rooms provide information
about and even encourage
self-harm
Peterson et al., 2008
o Addiction Hypothesis
 Self-injury may engage the endogenous opioid system which regulates
pain perception and endogenous endorphins
 Activation of the EOS can lead to an increased sense of comfort for
short period of time
 Repeated activation causes a tolerance effect
 Those who self-injure may feel less pain over time
 Overstimulation of the EOS can lead to withdrawal symptoms which may
result in NSSI in the absence of other triggers
o Social Contagion
 Hospitals
 Detention center
 Non-clinical settings
 Viewing NSSI in popular media
Whitlock, 2010
9
o Prior to 1990, self-injury in
the news was extremely
rare
o Research study found
1750 new stories related
to NSSI in 2000-2005
o Inaccurate portrayal of
NSSI in media
o Internet sites that portray
NSSI have increased
exponentially
Transue, L. and Whitlock, J. (2010).
oNew research shows

that peer pressure may
play a role
oSocial contagion effect
in media
oSocial media/social
contagion
Primary Motivations
10
o Seeking Release
from Internal
Emotions
o Regulating the
External
Environment
o Seeking Release of
Internal Emotions
 To stop bad feelings
 To relieve feeling
numb or empty
 To feel something,
even if its pain
 To punish yourself
 To feel relaxed
o Affect Regulation
 Anxiety
 Anger
 Frustration
 Depression
o Change Cognitions
 Distraction from problems
 Stops Suicidal thoughts
o Self Punishment
o Stop Dissociation
o Interpersonal
 Secure care and
attention
 Feel similar to peers
11
Pain Onset Pain Offset
o People who engage o When the pain

in NSSI are able to causing agent is
endure more pain removed or reduced
than other people. they feel better.
o They feel pain and o Don’t return to
find it very previous state, return
unpleasant. to even more positive
emotional state.
Franklin, 2014
Adapted from Nillumbik Community Health Service, 2012
o Ricardo
 14 years old
 Disengaged Family
 Depressed
 Struggling with his
sexuality
 Cutting extensively on
his legs and groin area
 Says this is the only
way to release the pain
and sadness
12
o Marshall
 18 years old
 Sexually abused by a family
friend for 3 years beginning
at age of 9
 Pierced his own genitals at
the age of 15
 Member of a ‘fight-club’
(boys who beat each other
severely while using drugs)
 Has 15 tattoos and 8 body
piercings (some self-done)
 Burns himself with cigarettes
on a daily basis
o Lucy
 13 years old
 Significant family conflict
 Poor interpersonal
relationships with peers &
some borderline traits
emerging
 Severe social anxiety with
panic attacks
 Cuts words like “slut”,
“whore”, and “sinner” into
her thighs
o Regulating the External Environment

 To avoid school, work, or other activities
 To avoid doing something unpleasant
 To avoid being with people
 To avoid punishment or paying consequences
 To get attention
 To try and get a reaction from someone, even if
it’s negative
 To receive more attention from your parents or
friends
13
o Regulating the External Environment
(continued)
 To receive more attention from your parents
 To feel more a part of a group
 To get your parents to understand or notice you
 To get control of a situation
 To get other people to act differently or to change
 To be like someone you respect
 To let others know how desperate you are
 To give yourself something to do when alone or with others
 To get help
 To make others angry
o Trey
 17 years old
 Athlete
 Turned to alcohol and
marijuana
 Started head banging
and beating self
 Told girlfriend when she
tried to end the
relationship that she
was the only person
who could make him
stop
o Charlotte
 16 years old
 Cheerleader at her school
 Obsessed with media and
popularity
 Her best friend started
cutting 2 years ago
 She cuts her arms very
superficially and the cuts are
visible
 Uses cutting as a bargaining
tool with parents to get
money and privileges
14
Often the two motivations noted previously
are both at play to varying degrees in a
given situation.
o Kaysha
 16 years old
 Enmeshed with Father/Lots of
Family Conflict
 Carves on her thighs when
parents fight to “make the
pain go away”
 Home-schooled, but doesn’t
do any work/threatens self-
harm and/or suicide when
parents confront her
 Girlfriend (who also does
NSSI) tried to break up with
her and she carved girlfriend’s
name on her leg
o Walsh (2006) argues that the relationship with

and attitude toward the body plays a central role
in the initiation and maintenance of NSSI.
o Brunner et al. (2007) reported that 9th graders

with history of NSSI who reported being
dissatisfied with their body had a three-fold
greater risk for engaging in repetitive acts of
NSSI.
15
o Walsh & Frost (2005) studied sample of inpatient
adolescents and found that those engaging in NSSI
reported greater body alienation, dissociation and eating
disorder symptoms than those without NSSI behavior.
o Ross, Heath, & Toste (2009) found that regardless of

gender, those participants reporting NSSI exhibited
greater body dissatisfaction than controls.
Cited in Muelenkamp & Brausch (2012)
o Body image significantly mediated the relationship

between negative affect and NSSI
o Body Image is a salient vulnerability factor when
developing models of predicting risk for NSSI
o Body image should be considered part of the etiological
model of NSSI.
o Body Image may be a critical feature contributing to
NSSI and could play a greater role in NSSI than
experiences of negative affect
o Implications for treatment: Body image and emotional
regulation should be addressed. Mindfulness and Body
Acceptance work may be helpful.
Increased emotional distress

+
Indifference to protect body
+
Decreased sensitivity to pain when facing
emotional distress
NSSI
16
The person appears to
turn on their own body
Psychological correlate
of an autoimmune
disorder
o Physical & Sexual Trauma

 Contribute to the sense of disregard for the
body
 Can lead to dissociation, which involves
physical and emotional numbing
o Trauma & Emotional Dysregulation
 Trauma can lead to greater degrees of
emotional and behavioral dysregulation
o Community Violence o School Violence

o Domestic Violence o Sexual Abuse
o Early Childhood o Terrorism
Relational o Traumatic Grief
o Medical Trauma
o Natural Disasters
o Neglect
o Physical Abuse
o Refugee/War Zone
17
o Parental Distress
 Fear of suicide
 Lack of understanding
 Relationship distress
o Sibling Distress
o Increase in overall
family distress
 Manipulation
 Disagreement on how to
respond
 Financial Strain/Access
Issues
o Social repercussions of
visible wounds
o Distress of School
Personnel
 Need to Report
 Misunderstanding of
the behavior
 Fear of Suicide
o Need for
Policies/Procedures
o Disruption of the
Learning Environment
o Distress among
Peers/Friends
 Misunderstanding
the behavior
 Fear of suicide
 Uncertainty about
how to
respond/whether
to report
o Strain on
Friendships
18
o Some of the research is pulled from BPD
o This should be done with caution.
o Differences in emotional processing have been
documented in BPD patients.
o Mixed evidence on altered physiological
reactivity in those with NSSI & related
pathology.
o fMRI results show a decrease of physiological
tension when imagining an act of NSSI.
Groschwitz & Plener, 2012
Neurotransmitters
o Serotonin-Inconsistent, deficiency more associated

with violent/aggressive behaviors
o Dopamine-Little consistent evidence of increases being
related
o Cortisol-Consistently lower levels seen in those with
NSSI/Hypo responsive HPA-axis in adolescents with
NSSI
o Endogenous Opioids-Lower levels with NSSI/could
explain the “addictive quality”
Analgesia/Opiate Hypothesis
o Related to lower levels of endogenous opioids
o NSSI typical performed in absence of physical
pain
o Those currently engaging in NSSI show higher
pain threshold than both ex-NSSI group and
healthy controls
o Suggests that Hypalgesia associated with NSSI
is habitual
19
o NSSI meets several criteria seen in addiction
(Nixon et al., 2002)
o Loss of control over the behavior
o Increasing tolerance
o Increased tension if NSSI not performed
o Victor, Glenn & Klonsky (2012)

o Found NSSI to be more related to Emotion Regulation
o Substance use is maintained by both positive & negative
reinforcement
o NSSI is primarily craved in the context of negative emotions
NSSI & Suicide
o NSSI typically considered:

o Maladaptive coping mechanism
o A symptom of distress that if unsuccessfully resolved may lead to
suicidal behavior
o Often used as a means of avoiding suicide
o Relationship between self-injury with suicidal intent and
self-injury without suicidal intent unclear as those who
engage in NSSI often report they have experienced more
thoughts of suicide or attempted suicide
o NSSI seems to be emerging as a significant risk factor
for suicide attempts
o Some studies have estimated around 60% of those who engage in NSSI
have gone on to attempt suicide
20
⦿ Intent/Purpose for Behavior
⦿ Severity/Lethality of
Method Used
⦿ Behavior Frequency
⦿ Number of Methods Used
⦿ Cognitive State During
Self-Harm
⦿ Consequences/Aftermath
Muelenkamp & Kerr, 2010
Characteristic NSSI Suicide Attempt
Intent/Purpose for Temporary Escape from Permanently terminate

Behavior Psychological Distress consciousness/end life
Create Change in Self To Escape Unbearable

or Environment Psychological Pain
Severity/Lethality of
Low High
Method Used
21
High, sometimes more

Low, typically 1-3
Behavior Frequency than 100 episodes/often
episodes
chronic and repetitive
Number of Methods Multiple Methods Single Methods used

Used used across episodes across episodes
Cognitive Status Distressed yet

Hopeless/Helpless
During Self-Harm Hopeful
Difficulty
implementing Inability to Problem
adaptive problem- Solve
solving
22
Consequences &
Aftermath
Frustration,
Intrapersonally Sense of relief, calm
Disappointment
Temporarily reduced
Increased Distress
Stress
Interpersonally Rejection, Criticism Others express care
from Others and concern
5 Questions Every Therapist

Should Ask During Assessment
o Everyone presenting for mental health services

 Particularly those in high risk groups
o Those with signs of self-harm should never be
ignored
 Clinicians are urged to add NSSI to their
intake paperwork
 Screening questions can lead to more
detailed queries
 e.g. DSM-5 Cross-Cutting Measures
(American Psychiatric Association, 2013)
23
Functional Assessment of Self-Mutilation
(FASM) & Alexan Brothers Urge to Self-
Injure Scale (ABUSI)
 Brief & Initial assessments of self-injury
Self-Harm Behavior Questionnaire (SHBQ)
 Brief initial assessment of both self-injury & suicide
Clinician-Rated Severity of Non-suicidal self-
injury
 Very brief clinician-rated scale
The Non-Suicidal Self-Injury Assessment

Tool (NSSI-AT)
 Developed by Whitlock & Purington
 Very thorough
Ottowa Self-Injury Inventory (OSI)
 Thorough clinical/research assessment of self-injury
Self-Injurious Thoughts & Behaviors
Inventory (SITBI)
 More extensive clinical/research assessment of both self-injury &
suicide
Caroline Kettlewell
(1999)
o Recommends that
therapists respond
to self-injury with
“respectful
curiosity”
24
o Assume the person is suicidal or refer to self-harm
using suicide language
o Respond to the person with emotionally charged
reactions such as:
 Anguish or Fear
 Recoil, shock, avoidance, disdain
 Condemnation, Ridicule, Punishment
 Patronizing or pity
o Quickly try to get them to stop the behavior
o Quickly present them with a safety contract
Once the presence of

NSSI has been
established, there are
Five Key Questions
that should be
answered by the
clinician...
1. What are the Functions of the Behavior?

2. What are the Recency & Frequency of the
Behavior?
3. What is the Severity of the Behavior?
4. What Triggers the Behavior?
5. Who is Aware of the Behavior?
25
o Why does the
person engage in
NSSI?
o How insightful are
they about their
motivations?
o How honest are they
about their
motivations?
o To Deal with Anger

o To Feel Something o To Avoid Committing
o My Friends Do It Suicide
o To Get A Rush o To Relieve Stress or
o As Self-Punishment Pressure
o To Deal with Frustration o Because I like the way it
o To Cope with looks
Uncomfortable Feelings o To Change my
o Because it Feels Good Emotional Pain to
o To Shock or Hurt Physical Pain
Someone o Because of my self-
o To Get Control Over My hatred
Life o As an attempt to Commit
Suicide
o When was the most

recent episode of NSSI?
o How likely are they to do
it again?
o On how many occasions
has the person engaged
in NSSI?
o What was the age of
onset?
26
o What is the location of o What is the person’s
the wound/s? Pattern of Practice?
o Was the person under o In Private?
the influence of drugs or o In the Presence of
alcohol? others?
o Have they ever injured o Let others hurt
themselves more them?
severely than
o Have hurt others?
planned/required
medical attention?
o Regular routine?
o How often does NSSI o Regular room or
occur? place?
o Is NSSI cyclical?
o Three types of
triggers or
antecedents:
o Environmental
o Physical
o Social
o Biological
o Physical
o Substances
o Psychological
o Cognitive
o Affective
o Behavioral
o Has the person

told anyone?
o Does anyone
suspect the self-
harm?
o Would they be
willing to disclose
this to someone?
27
o Try to approach the student in a calm and caring way
o Accept him/her even though you may not accept the
behavior
o Let the student know that there are people who care
about him/her
o Understand that this is a way of coping with the pain
he/she feels inside
o Use the student’s language for NSSI
o Show a respectful willingness to listen
o Have a non-judgmental compassion for their
experience
Toste & Heath, 2010
o Don’t be reactive as this could alienate students and

damage the developing alliance
o Don’t respond with panic, revulsion, shock, or averted
gaze
o Don’t use threats or ultimatums
o Don’t permit the student to relive the experiences of
NSSI in detail, as this can be triggering
o Don’t Talk about the NSSI in front of the class or
around peers
o Don’t promise that you won’t tell anyone if he/she
shares the NSSI with you (consider reporting rules)
28
Suicide Risk Assessment
o Two important factors in assessing suicide risk

 Depression
 Hopelessness
o Does the person have suicidal ideation/thoughts?
o Does the person have a suicide plan?
o Do they have the means to carry out the plan?
o Do they have the intent to carry out the plan?
o Risk Factors: Isolation, Loss of Relationships or Job,
Mental Illness, Substance Abuse, Impulsivity, Family
History of Suicide or Attempts…
o Determine the level of

severity of the physical
injury
 Consider Medical Factors
 Infection
 Bleeding
 Internal Injury
 Consider Referral to
PCP/Specialists
o Consider Co-Occurring
Disorders/Mental Status
o Drug Use
o Level of Impulsivity
o Support System
o Peer Influence
Multi-Systemic Approach
29
o Replacement Skills Training
o Dialectical Behavior Therapy
o Cognitive Behavioral Therapy
o Psychodynamic Therapy
o Manual Assisted Cognitive Therapy
o The Cutting Down Programme
o Pathways to Possibilities
o Collaborative Strengths-Based Group Therapy
Therapy Intervention State of Research Support
Dialectical Behavior Therapy Showing some promise/Probably

(DBT) efficacious
Cognitive Behavior Therapy Showing some promise/Probably

(CBT) efficacious
Family Interventions Showing some promise/Probably

(Broadly Defined) efficacious
Group-based Interventions Very Little Research/Established

(Broadly Defined) Treatment
o No theoretical
orientation or approach
has emerged as
substantially more
effective than others.
o However, there are
some common elements
within what we know
works.
30
A Common theme Therefore:
across treatment
approaches is the A Multi-Systemic
need to work with Approach
multiple systems
within which a
client lives, works,
and plays.
o Home
o Family (Immediate &
Extended)
o School
o Friends
o Online Communities
o Work
o Religious Community
o Mental Health
Professionals
o Medical
o Case Management
Those from various

systems are
brought in as it is
relevant for the
individual client.
31
“Evidence-Based
Practice (in
Psychology) is the
integration of the best
available research
with clinical expertise
in the context of
patient www.apa.org
characteristics,
culture, and
preferences”
o Interventions of o Clients usually move

different levels of through less
intensity available intensive treatment
o Client’s needs are before receiving
matched to the more intensive
appropriate level o Moving up steps is
o Outcomes carefully usually associated
monitored so that with increasing risk,
treatment can be intensity, and
“stepped up” expense
Walsh, 2006
Working with Parents & Guardians
32
o Agency or Organization
Policies
o State Law
o Clinical Judgment
o Considerations:
 Severity of the injury or
injuries
 Extent of the injury or
injuries
 Suicide Risk
 Need for monitoring
outside the agency or
organization
 Documentation
“We just don’t o Parents may be

understand this at feeling any or all of
all” these:
“We don’t want our  Shock & Denial
 Anger & Frustration
child to die”  Empathy, Sympathy
“We have no idea & Sadness
where this is coming  Guilt
 Fear & Panic
from”
 Loss of Control
“We’re terrified that this is  A sense of isolation
practice for suicide”
o Parents need to feel that they understand

the problem
 Provide Education through consultation &
appropriate educational materials
 Help them to understand the function/s this
behavior serves for their child
 Guide them past the emotions of the situation
so that they can make informed decisions
 Develop a Treatment Plan
 Assist them in opening communication
channels and keeping them open
33
o Most parents need ongoing consultation
from a professional in order to:
 Manage feelings of frustration, guilt, anger, etc.
 Keep healthy communication channels open
with their child
 Respond appropriately to:
 Episodes of self-harm
 Child’s attempts at controlling relationships through
NSSI
 Understand the Stages of Change
Courtney-Seidler et al. (2014) found that:

o Parents of those who engage in NSSI
 Communicate invalidation-minimization, criticism,
punishment, distress
 Tend to de-escalate negative interactions with their
teens only after it becomes “highly aversive” and
even then to a lesser degree than normative
o Intervention needs to address this
 Parents must manage their communication (verbal
& non-verbal)
 Parents must learn to de-escalate situations sooner
and to a greater degree
o Offer clinicians
MINIMAL protection Never introduce a
from liability
o Can comfort parents safety contract
o Could offer some before the client is
clients comfort ready!
o Best when they
include replacement
behaviors
34
o Offer clinicians
MINIMAL protection
from liability
All Safety Contracts o Can drive behavior
Should Include a HOLD underground
HARMLESS Provision! o Little Evidence
Supporting their
Efficacy
o Can create undue
pressure from
parents
o Help client make a list of replacement

behaviors
 Make it on the computer and decorate it
 Turn it into an art project/Get creative!
 Provide a Handout or Other resource to your client
 Offer a Handout or Other resource to your client
o Help your client and their family collaborate on
a contingency plan
 Allay parental fears so that they can be available
 Guide parents in the ability to be present in a non-judgmental
manner
o Parents need guidance

about how to monitor
NSSI.
o The following can do
more harm than good:
 Room Searches
 Strip Searches
 Offering incentives
for “No-Harm”
 Punishing NSSI
 Threats &
Ultimatums
35
o Adolescents report that having non-
judgmental adults to talk to can help curb
NSSI
 The Best Monitoring is done through direct,
honest communication
 “Respectful Curiosity”
 In some cases, searches might be necessary
 These must be done with sensitivity and respect for
privacy
 Power & control struggles must be avoided
o Parents will have an

innate desire to control
o Teens will have an
innate resistance to
being controlled
o Frequently, professional
help is needed in
navigating this balance
The Role of the School
36
o Allows the clinician to involve members of
multiple systems in treatment
 Supportive Peers
 Friends/Group Peers
 Significant Others
 Supportive Adults
 Teachers
 Coaches
 Clergy
 Caseworkers
Selekman, 2006
o Walsh (2006) urges

schools to develop
NSSI protocols
 Educates personnel
about the problem
 Clarifies roles and
responses
 Offers resources &
referrals
 Guides the
management of
contagion effects
o School counselors are

bound by ethics to honor
privacy
o Some courts have ruled
that this privacy exists
with the parent NOT the
student
o School counselors must
comply with district
policies
o Districts are often quite
conservative with
reporting requirements
37
o Safe Adult with
whom to talk
o Modification of
workload
o Support in
practicing healthy
coping skills
o Protecting Self-
Esteem
o Minimizing
opportunities for
NSSI
o Monitoring overall
functioning
o Maintaining
contact with other
stakeholders
The Role of Peers
38
o In addition to
understanding
NSSI, peers need
to know their
limits
o This is essential
for the well-being
of all involved
o Never promise to keep a secret

 Telling isn’t always a bad thing
 Your friend might “hate” you for a while, but
someday they’ll thank you
o Never take responsibility for someone’s
safety on yourself
 Tell a trusted adult
 Encourage your friend to tell others
 Get help/Call a helpline
o Don’t be afraid to
ask
o Never
underestimate the
power of a
friendship
o Encourage
o Share healthy
resources
39
o Ask them how they’re
doing
o Offer to draw a butterfly
on their skin (The
Butterfly Project)
o Tell someone or
encourage them to do
so
o Always report suicidal
ideation
o Bullying does appear to be a risk factor

for NSSI
 Can be particularly relevant in cases where
there’s: family history of attempted/completed
suicide, mental health problems, history of
physical maltreatment by an adult
o “Be More Than a Bystander”
(www.stopbullying.gov)-USDHHS
campaign
o “Know Bullying” App from SAMHSA
The Role of Social Media
40
Supportive Communities:
● Chronicle Me
● Self-Harm Support
Groups on:
 Facebook
 Instagram
 self_harming_and
_depression
 Twitter
 @StopSelfHarm
 Tumbler
o Questions to
consider:
 Is the site
moderated?
 By Whom?
 Does it have Trigger
Alerts?
 What are the
community rules?
 Is it for support &
encouragement?
 Is pro-NSSI content
allowed?
o Social Media can

afford teens
contact with
others
 Social Support
 Encouragement
 Sense of not being
alone
 Those in rural
areas can connect
to resources
41
o To Write Love on Her Arms
 www.twloha.com
o S.A.F.E. Alternatives (Self Abuse Finally
Ends)
 www.selfinjury.com
o Self Injury Outreach & Support
 www.sioutreach.org
o Self Injury Foundation
 www.selfinjuryfoundation.org
o Unhealthy
relationships can
form
o Misinformation
o Triggering Images or
content
o Some sites condone
NSSI
Negative Replacement Behaviors
42
o Offer alternative
forms of “harm”
o Controversial
o Can serve a
transitional
purpose early in
treatment
o Use with caution
o Using a red marker or paint to simulate blood

on the body
o Applying ice packs or holding frozen objects for
the pain sensation
o Applying a temporary tattoo and scratching it off
with the fingernails
o Writing in detail about a self-injury episode
o Applying cooling cream (Ben Gay) to the skin
o Snap a rubber band on your wrist
o Eat hot (spicy) foods
o Movie makeup scars!
o Considering Readiness for Change

o The Professional’s low-tolerance for self-harm
can cause us to rush-Righting Reflex
o Parents are ready for change NOW!
o The client will change (stop the behavior) when
they are ready
o It is our job to get them ready, NOT to change
them
o We can treat NSSI AND manage our risk
43
o Precontemplation
 Unaware of problem behavior or unwilling (or discouraged)
regarding change
 The person’s perception regarding the problem behavior
has not shifted from positive to negative
 There is no intention to change behavior in the forseeable
future
Question for Brainstorming: What do clients need at this

stage?
“It isn’t that they can’t see the solution. It is that they
can’t see the problem” (G.K. Chesterson)
o Contemplation
 Quite aware that a problem exists and seriously thinking
about overcoming it
 There is no commitment to take action in this stage
 The person is quite open to information about the behavior
 The person is open to exploring the ‘decisional balance’ with
regard to the behavior
 Exploring the pros and cons of the problem and the solution/s
Question for Brainstorming: What interventions would you

use at this stage?
o Preparation
 Person intends to take action in the next month and have
unsuccessfully taken action in the past year
 Some reductions in behavior may have been made (i.e.
substituting alternate behaviors, reduced frequency etc.)
 Person has not yet met the criterion for effective action
 Some people consider this stage the ‘early stirrings’ of the
action stage
Question for Brainstorming: What are pitfalls for

clinicians at this stage?
44
o Action
 People make the move and
implement the plan they have
been contemplating
 Changes made here are most
visible to others and receive
the most recognition
 Action is not always
equivalent to change
(maintenance is most
indicative of change)
o Maintenance, Relapse, & Recycling

 Consolidation of the change
 This is an ACTIVE stage
 SOC recognizes that relapse is possible (even likely)
 People often ‘recycle’ through numerous stages
several times before success
 People who relapse often have a better chance of success
during the next cycle through the stages
Six Key Components of

Therapeutic Intervention
45
1. Addressing Underlying Mental Health Issues
2. Building Coping Skills
3. Enhancing Self-Esteem & Self-Acceptance
4. Improving Relationships & Relational Skills
5. Addressing Trauma (Big T & Little T)
6. Developing Problem Solving Skills
o Mood Disorders
o Attention &
Executive
Functioning
Disorders
o Substance Use
o Learning Disorders
o Autism Spectrum
Disorders
o Distraction
Strategies (see
next slide)
o Development to
healthy coping
strategies in
individuals and
their families
46
Draw on your arm with a
Throw Eggs in the
red felt-tip pen
BREATHE
Cook Shower
Hold an ice cube Go Out & Be Around People
Use warm red food coloring on
your arm to simulate blood
Cry Sing at the TOP of your Lungs

Put stickers on the part of
your body you want to Draw Slashing Lines
injure
on a piece of paper
o Internal states and environmental situations

dysregulate the person
o Coping skills enable the person to re-regulate
o Learning effective coping skills feeds back into
the person’s sense of confidence and control
over their life
Question for Brainstorming: How do you

help your clients build coping skills? What
skills are important?
● Herbal Tea
● Chocolate
● Poetry
● Religious symbols
● Pictures of friends
● Recorded messages
● Music
● Art Supplies
● (Consider) Inclusion of
Self-Harm
Paraphernalia
47
o Those engaging
in NSSI often
have a poor self-
concept
o This can produce
self-loathing and a
negative body
image
o Some are victims
of past abuse
o Walsh (2012) suggests six dimensions of body

self-concept:
o Attractiveness-Feeling attractive and receiving feedback from
others that one is attractive
o Effectiveness-Coordination, athleticism, stamina
o Health-Objective (how physically well is the person) &
Subjective (how well does the person feel)
o Sexual Characteristics-Comfort/Discomfort with the body
following puberty
o Sexual Behavior-Comfort/Discomfort with sexual activity with
oneself/others
o Body Integrity-Feeling that one owns or occupies one’s body
o Increasing
acceptance of and
comfort in & with
one’s own body
o Helping clients
learn to care for and
love their bodies
o This is a key
developmental task
of adolescence.
48
o Me & Me2 Activities Question for
o Acknowledging Brainstorming:
one’s own strengths What activities
and weaknesses
do you use to
o Hearing from others
what they like about build self-esteem
you and positive
o Observing & Feeling self-concept in
that one is valued by your clients?
others
o There is some
suggestion that
those engaging in
NSSI have deficits
in:
o Accurately reading
emotional cues from
others
o Accurately conveying
their own emotions
through expression
o Improving family relationships can set the stage

for improvements
 Improved communication
 Increased openness
 Better emotional regulation
o Improving Peer Relationships
 Positive Support
 Learning to manage and minimize emotional
dysregulation (Cutting the Drama)
 Reading the Feedback Accurately
49
o Big “T” Trauma
 Trauma will likely
need to be treated in
addition to the self-
harm
o Little “T” Trauma
 Tends to be more
relational
 Can be quite
insidious
 Person likely doesn’t
recognize it as
trauma
o Relational Trauma
 There is a rupture in a significant relationship or
relationships
 This influences the concept of oneself
 Sets the expectation from others
o Leads back to the improvement of
relationships and relational skills
 Family Therapy
 Communication & Relationship Skills
 Social Skills
Relational Deficits,
Negative Emotions,
Negative Expectations,
Poor Coping Skills &
Low Self-Esteem
converge to create poor
problem solving
capabilities
50
o Teens must feel that they can solve problems
before they will
o Simple problem solving models are very
helpful:
 What is the Problem?
 Is the problem mine to solve?
 What are the possible solutions?
 What are the pros & cons of each?
 Which solution is best?
 With whom could I consult if I have doubts or
questions?
 How do I implement the chosen solution?
The Role of Adjunctive Treatments
o Communication
o Removal of
Secondary Gains
o Developing
appropriate
boundaries
o Developmentally
appropriate
parenting
51
● Psychoeducational
Group Therapy
● Interpersonal
Process Oriented
Group Therapy
● Integrated
Psychoeducational &
Process Group
Therapy
o Groupworks Model
(www.drtlsheppard.com)
 Heterogeneous groups for gender & presenting
issue
 Ongoing/Open format
 Structured Interpersonal Process Work
 Skills Building/Psychoeducational Component
 Techniques and Theoretical Grounding from:
 Cognitive Behavioral Therapy
 Interpersonal Therapy (Broadly Defined)
 Dialectical Behavior Therapy
 Interpersonal Neurobiology
o The Power of Group is in its Therapeutic

Factors (Yalom & Leszcz, 2005):
 Universality
 Interpersonal Learning
 Instillation of Hope
 Development of Socializing Techniques
 Altruism
 Cohesiveness
 Imparting Information
52
● Many pediatricians refer
self-harming
adolescents to a
psychiatrist
● Medications targeting
serotonergic,
dopaminergic, and
opioid systems have
shown the most promise
o Typically become
involved when there
is a medical need
 Infection
 Need for suture
 Need for further
medical assessment
o These professionals
are sometimes the
least trained
o Serotonergic system-Serotonin implicated in

impulsivity and depression
 SSRI’s such as Prozac, Zoloft, Paxil, Lexapro, etc.
o Opiate system-There may be habituation to
high levels of endogenous opioids during
childhood
 Naltrexone (Vivitrol) is an opiate agonist
o Dopaminergic system-Implicated in
dysregulation
 Atypical antipsychotics, mood stabilizers, and alpha-
2 agonists
53
(Glenn, Franklin & Nock, 2014)
o Treatments showing the most promise
include:
 Family Skills Training
 Family communication & problem-solving
 Parent Education & Training
 Monitoring & Contingency Management
 Individual Skills Training
 Emotion Regulation (DBT, CBT, Interpersonal,
Group)
 Problem Solving (DBT, CBT, Interpersonal, Group)
The Essentials
o Screening for NSSI

at intake
 Including NSSI in
“Safety” and “Risk”
Assessment
 Including NSSI in all
documentation
 Accurate
documentation &
diagnosis
 Appropriate
Treatment Planning
54
o Schools tend to have stricter reporting rules
than mental health settings
o Factors in decision-making
 Severity of the injuries
 Presence of suicidal ideation, plan, intent
 Frequency & Intensity of self harm
 Stage of Change
 How many people are aware
 Family Environment
o Hospitalization
 Most of those who engage in NSSI don’t meet
criteria
o Referral to Physician or Other Health

Care Professional
 Severity of wounds
 Risk of Infection
 Ability of patient/family to care for wounds
 Need for suture or other specialized care
 Risk of disease transmission
 Prevention of scarring
 Family Preference/Peace of Mind
Clinically, it’s often recommended to

downplay occurrences
Legally, the management of risk often

pushes toward reporting or referring for
additional assessment or attention
55
www.drtlsheppard.com
56

Bibliography
Speaker Name: Tony L. Sheppard, Psy.D., CGP, FAGPA11
Title: 11 Essentials for Self-Harm Recovery: Helping Children & Teens Reclaim Their
Lives
Bentley, K.H., Nock, M.K., & Barlow, D.H. (2014). "The four function model of non-suicidal
self-injury: key directions for future research." Clinical Psychological Science, 2(5) 638-656.
Maciejewski D.F., et al., (2014) "Overlapping genetic and environmental influences on

nonsuicidal self-injury and suicidal ideation: different outcomes, same etiology?" Comparative
Psychiatry, 53 (6) 691-700.
Saraff, P.O., Trujilo, N. & Pepper, C.M. (2015). "Functions, consequences, and frequency of non-
suicidal self-injury." The Psychiatric Quarterly, [E-published ahead of print].
Glenn, J.J. et al. (2014). "Pain analgesia among adolescent self-injurers." Psychiatry Research,
220(3) 921-6.
Whitlock, J., Exner-Cortens, D. & Purington, A. (2014). "Assessment of nonsuicidal self-injury:

development of initial validation of the non-suicidal self injury assessment tool (NSSl-AT).
Psychological Assessment 26 (3), 935-46.
Gonzales, A.H. & Bergstrom, L. (2013). Adolescent non suicidal self injury (nssi) interventions,
Journal of Child & Adolescent of Psychiatric Nursing 26 (2) 124-30.
Washburn, J .J. et al. (2012). Psychotherapeutic approaches to non-suicidal self injury in

adolescents. Child & Adolescent Psychiatry & Mental Health. 6 (1) 14.
57
Example of Interview Form with Screening Question for NSSI
11 Essentials for Self-Harm Recovery
Assessment Interview Form-Child/Adolescent (Office Version)
Name:___________________________________Date:________________
Family/Living Situation (Genogram):
Reason for Referral Why did you come for the appt? Did you want to come? Y N
Previous Therapy/Evaluation Changes in Treatment/School?
School
Where do you go to school? Grade:
Like school? Y N Grades: Strengths:
Weaknesses:
Special Ed?
Behavior Problems:
Detention/Suspensions/Expulsion?
Current Medications
Interpersonal
Friends:
Safety/Well-Being
Suicidal Thoughts Plan Intent Attempts Y N
Homicidal Thoughts Plan Intent Attempts Y N
NSSI Current Y N History Y N Location?
Abuse/Neglect
Prescribed by:
58
MSE
Appearance N/A or OK Slight Moderate Severe
Unkempt, disheveled ( ) ( ) ( ) ( )
Clothing, dirty, atypical ( ) ( ) ( ) ( )
Odd phys. characteristics ( ) ( ) ( ) ( )
Body odor ( ) ( ) ( ) ( )
Appears unhealthy ( ) ( ) ( ) ( )
Posture N/A or OK Slight Moderate Severe
Slumped ( ) ( ) ( ) ( )
Rigid, tense ( ) ( ) ( ) ( )
Body Movements N/A or OK Slight Moderate Severe
Accelerated, quick ( ) ( ) ( ) ( )
Decreased, slowed ( ) ( ) ( ) ( )
Restlessness, fidgety ( ) ( ) ( ) ( )
Atypical, unusual ( ) ( ) ( ) ( )
Speech N/A or OK Slight Moderate Severe
Rapid ( ) ( ) ( ) ( )
Slow ( ) ( ) ( ) ( )
Loud ( ) ( ) ( ) ( )
Soft ( ) ( ) ( ) ( )
Mute ( ) ( ) ( ) ( )
Atypical (e.g., slurring) ( ) ( ) ( ) ( )
Attitude N/A or OK Slight Moderate Severe
Domineering, controlling ( ) ( ) ( ) ( )
Submissive, dependent ( ) ( ) ( ) ( )
Hostile, challenging ( ) ( ) ( ) ( )
Guarded, suspicious ( ) ( ) ( ) ( )
Uncooperative ( ) ( ) ( ) ( )
Affect N/A or OK Slight Moderate Severe
Inappropriate to thought ( ) ( ) ( ) ( )
Increased lability ( ) ( ) ( ) ( )
Blunted, dull, flat ( ) ( ) ( ) ( )
Euphoria, elation ( ) ( ) ( ) ( )
Anger, hostility ( ) ( ) ( ) ( )
Depression, sadness ( ) ( ) ( ) ( )
Anxiety ( ) ( ) ( ) ( )
Irritability ( ) ( ) ( ) (___)
Perception N/A or OK Slight Moderate Severe
Illusions ( ) ( ) ( ) ( )
Auditory hallucinations ( ) ( ) ( ) ( )
Visual hallucinations ( ) ( ) ( ) ( )
Other hallucinations ( ) ( ) ( ) ( )
59
Cognitive N/A or OK Slight Moderate Severe

Alertness ( ) ( ) ( ) ( )
Attn. span, distractibility ( ) ( ) ( ) ( )
Short-term memory ( ) ( ) ( ) ( )
Long-term memory ( ) ( ) ( ) ( )
Judgment N/A or OK Slight Moderate Severe
Decision making ( ) ( ) ( ) ( )
Impulsivity ( ) ( ) ( ) ( )
Thought Content N/A or OK Slight Moderate Severe
Obsessions/compulsions ( ) ( ) ( ) ( )
Phobic ( ) ( ) ( ) ( )
Depersonalization ( ) ( ) ( ) ( )
Delusions ( ) ( ) ( ) ( )
Orientation: Time __ Place ______ Person
Eye contact: WNL Poor Variable Odd __________________
Worry: Y/N Depression:
Appetite: WNL Poor Variable Overeating Weight Loss/Gain
Sleep Problems: Y N Initiation Maintenance Hypersomnolence Difficulty Awakening
How Many Hours of Sleep per Day Quality?

How would you rate the following on a 0-10
Insomnia Cause? Restlessness/Thoughts/Worry/Unknown scale?
Self Confidence:
Nightmares/Bad Dreams?
Overall Happiness:
Substance Use/Abuse Feelings About the Future:
Relationships:
Family Hx? Y N
Behavior Observations/Examiner Notes:
Goals for Treatment?
1.
2.
3.
Rev. 7/10
C/A Office Interview
GWKS
Revised 1/15
Copyright 2015, Groupworks, Inc.

60
The Non-Suicidal Self-Injury Assessment Tool

(NSSI-AT)
Developed by: Janis Whitlock and Amanda Purington

The Cornell Research Program on Self-Injury and Recovery
www.selfinjury.bctr.cornell.edu
Revised: March 15, 2013
How to Interpret this Document: This document shows main questions as well as sub-
questions, as indicated in colored text. The response option that triggers a sub-question
will appear in color (most are blue, though other levels of sub-questions also appear in
red). The sub-question that relates to that response option appears immediately below
and is in the same color as the response option that triggers the sub-question. If more
than one sub-question follows from this one response option, the additional sub-
questions appear below in the same color. If a sub-question has another sub-question
within it, the same pattern follows (the response option that triggers the sub-question is
in a color that matches the color of the text of the sub-question below) though it will be in
a different color from the first sub-question.
Citation: Whitlock, J.L., Exner-Cortens, D. & Purington, A. (under review). Validity and
reliability of the non-suicidal self-injury assessment test (NSSI-AT).
1
© 2007. Cornell Research Program on Self-Injurious Behaviors in Adolescents and Young Adults
www.crpsib.com
61
A. Primary and secondary NSSI characteristics

1. Have you ever done any of the following with the purpose of intentionally hurting
1
yourself?
o Severely scratched or pinched with fingernails or other objects to the point that
bleeding occurs or marks remain on the skin
o Cut wrists, arms, legs, torso or other areas of the body
o Dripped acid onto skin
o Carved words or symbols into the skin
o Ingested a caustic substance(s) or sharp object(s) (Drano, other cleaning
substances, pins, etc.)
o Bitten yourself to the point that bleeding occurs or marks remain on the skin
o Tried to break your own bone(s)
o Broke your own bone(s)
o Ripped or torn skin
o Burned wrists, hands, arms, legs, torso or other areas of the body
o Rubbed glass into skin or stuck sharp objects such as needles, pins, and staples
into or underneath the skin (not including tattooing, body piercing, or needles
used for medication use)
o Banged or punched objects to the point of bruising or bleeding
o Punched or banged oneself to the point of bruising or bleeding
o Intentionally prevented wounds from healing
o Engaged in fighting or other aggressive activities with the intention of getting hurt
2. Are there any other ways that you have physically hurt or mutilated your body with the
purpose of intentionally hurting yourself?
o Yes; please specify
o No
B. Functions
3. How true are the following statements about why you hurt yourself? Please select the
most accurate response.
I hurt myself… Strongly Somewhat Somewhat Strongly

Disagree Disagree Agree Agree
(1) (2) (3) (4)
o …to feel something
o …because my friends hurt
themselves
o …as a self-punishment or to atone
for sins
o …to get a rush or surge of energy
o …to deal with frustration
o …to cope with uncomfortable
feelings (e.g., depression or
1
Note: It is not advisable to use a behavior-based NSSI screening item with secondary
school students. Single item measures, while slightly less effective, are preferred in this
population. The replacement measure we use is, “Have you ever hurt your body (e.g.
cut, carve, burn, scratch really hard, punch) on purpose but without wanting to end your
life?
2
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62
anxiety)
o …in hopes that someone would
notice that something is wrong or
that so others will pay attention to
me
o …so I do not hurt myself in other
ways
o …because it feels good
o …to deal with anger
o …to get control over myself or my
life
o …to shock or hurt someone
o …to avoid committing suicide
o …because I get the urge and
cannot stop it
o …to relieve stress or pressure
o …to change my emotional pain into
something physical
o …because of my self-hatred
o …because I like the way it looks
o …as a way to practice suicide
o …as an attempt to commit suicide
o Other, please describe
4. In the above question, you indicated that you intentionally hurt yourself with
the intention of practicing or committing suicide. Was practicing or
attempting suicide the primary reason you intentionally hurt yourself?
o Yes
o No
o I am not sure
If only these items are indicated or if #4 is answered yes, we exclude these

individuals from the NSSI track and recode as no NSSI
C. Recency and Frequency (and age of cessation)
5. The following questions ask about your experience with intentionally hurting yourself. We
know that this can be a difficult issue to think and talk about. Please note that there are
web links on the bottom of every page and at the end of the survey with contact
information you can use if you feel like you want to talk with someone. There is also a
distraction button you can use to take a break if you start to feel triggered or at all
uncomfortable. The information you provide about this topic will be used to help others
who intentionally hurt themselves. It will take about 15 more minutes to complete this
survey. Thank you in advance for your time and honesty.
~~~~~~~~ When was the last time you intentionally hurt yourself in one of the ways
listed in the previous question?
o Less than 1 week ago
o Between 1 week and 1 month ago
o Between 1 and 3 months ago
o Between 3 and 6 months ago
o Between 6 months and 1 year ago
o Between 1 and 2 years ago
o More than 2 years ago
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6. How likely are you to intentionally hurt yourself again?

o Very likely
o Somewhat likely
o Not sure
o Somewhat unlikely
o Very unlikely
7. How old were you the last time you self-injured?
8. Approximately on how many total occasions have you intentionally hurt yourself?
o Only once
o 2-3 times
o 4-5 times
o 6-10 times
o 11-20 times
o 21-50 times
o More than 50 times
9. If you had to estimate the total number of occasions you have intentionally hurt yourself,
what would you estimate?
D. Age of onset and cessation
10. How old were you the first time you intentionally hurt yourself?
E. Wound Locations
11. On what areas of your body have you intentionally hurt yourself?
o Wrists
o Hands
o Arms
o Fingers
o Calves or ankles
o Thighs
o Stomach or chest
o Back
o Buttocks
o Head
o Feet
o Face
o Lips or tongue
o Shoulders or neck
o Breasts
o Genitals or rectum
o Other; please specify
F. Initial Motivations
12. Which of the following descriptions best describes your motivations for first intentionally
hurting yourself? (Please check all that apply)
o A friend suggested that I try it
o I read about it on the Internet and decided to try it
o I saw it in a movie / on television or read about it in a book and decided to try it
o It seemed to work for other people I know
o It seemed to work for celebrities I have heard of
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o I accidentally discovered it - I had never heard of it or seen it before

o It was part of a dare
o I did it because I had friends who did it and I wanted to fit in
o I wanted to be part of a group
o I wanted to shock or hurt someone
o I was upset and decided to try it
o I wanted someone to notice me and / or my injuries
o It felt good
o I was angry at someone else
o I was angry with myself
o I was drunk or high
o I cannot remember
G. Severity
13. Have you ever intentionally hurt yourself more severely than you expected?
o Yes
o No
14. Have you ever intentionally hurt yourself so badly that you should have been seen by a
medical professional (even if you were not)?
o Yes
o No
15. How many times have you intentionally hurt yourself more severely
than you expected?
o 1
o 2-3
o 4-5
o More than 5
16. Were you under the influence of drugs or alcohol in any instance that
you hurt yourself more severely than you expected?
o Yes
o No
17. Please briefly describe one specific thing you have done to intentionally hurt yourself.
18. Have you ever sought medical treatment (not therapy) for any of the physical injuries you
intentionally caused?
o Yes
o No
19. How often have you intentionally hurt yourself while you are in your most active
phase(s)?
o Every day
o 2-3 times a week
o Once a week
o 1-3 times a month
o Once every few months
o About once a year
o Once every two years or more years
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20. During the period(s) in which you most actively hurt yourself, what was the longest
interval of time during which you did not hurt yourself?
o Less than a week
o Less than a month
o 1-3 months
o 4-6 months
o 7-12 months
o More than a year
H. Practice Patterns
21.
How true are each of Strongly Somewhat Neither Somewhat Strongly Does
the following disagree disagree agree agree agree not
statements for you? (1) (2) nor (4) (5) apply
disagree
(3)
I always intentionally
hurt myself in private
I sometimes
intentionally hurt myself
in the presence of
others
I sometimes let other

people intentionally hurt
me physically
I have intentionally
physically hurt another
person
I have a regular routine

I follow when I
I have a particular place

/ room I prefer to be in
when I intentionally hurt
myself
I tend to go through
periods in which I
intentionally hurt
myself, then periods in
which I do not, and this
pattern repeats
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I. Habituation and Perceived Life Interference

22.
How true are each of Strongly Somewhat Neither Somewhat Strongly Does
the following disagree disagree agree agree agree not
statements for you? (1) (2) nor (4) (5) apply
disagree
(3)
I have had to
more deeply and / or in
more places on my
body over time to get
the same effect
I want to stop
intentionally hurting
myself altogether, but
have trouble stopping
I will not need help from

someone to stop
myself altogether - I can
do it on my own
Nothing else works as

well as intentionally
hurting myself to calm
me down or give me
relief
I have had to fight the

urge to start
myself again
When I have the urge to

it is easy to control it
23. The fact that I intentionally hurt myself is a problem in my life.

o Strongly disagree
o Somewhat disagree
o Neither agree nor disagree
o Somewhat agree
o Strongly agree
24. The fact that I intentionally hurt myself interferes with: (Please check all that apply)
o Relationships which are important to me
o My ability to complete school or work obligations
o My ability to take care of myself (eat right, exercise, etc.)
o My ability to engage in hobbies or things that I like to do
o My self-worth / self-esteem
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o The clothing I wear

o It does not interfere with my life in any way
J. NSSI Disclosure
25. Does the following statement describe your experience? Someone knows that I
intentionally hurt myself and has had a conversation with me about it.
o True
o False
26. Who knows about it and has talked with you about it?
o Parent or custodial guardian
o Sibling
o Friend
o Significant other (boyfriend, girlfriend, or spouse / partner)
o Other relative
o Teacher
o Coach
o Adult friend
o Therapist
o Physician
o Religious or spiritual leader (e.g., priest, pastor, rabbi)
o Health care provider
27. (For each selected) Did you initiate the conversation or did they?
o I initiated the conversation
o They initiated the conversation
28. (For each selected) Have the conversation(s) you've had with this person
been helpful?
o Yes
o No
o I do not know
29. Does the following statement describe your experience? One or more people know or
suspect that I intentionally hurt myself but have not had a conversation with me about it.
o True
o False
o Possibly, but I do not know
30. Who knows / suspects about it and has not talked with you
about it? (Please check all that apply)
o Parent or custodial guardian
o Sibling
o Friend
o Significant other (boyfriend, girlfriend, or spouse / partner)
o Other relative
o Teacher
o Coach
o Adult friend
o Therapist
o Physician
o Religious or spiritual leader (e.g., priest, pastor, rabbi)
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o Health care provider

31. (For each selected) Do you wish this person would talk with you
about it?
o Yes
o No
o I do not know
32. Does the following statement describe your experience? No one knows that I
intentionally hurt myself.
o True
o False
K. NSSI Treatment Experiences

33. Have you ever gone to therapy because you intentionally hurt yourself?
o Yes
o No
o Intentionally hurting myself was part of the reason I went but not all of it
34. Did someone else insist you go to therapy or did you decide to go on
your own?
o Someone else insisted that I go
o I went on my own
35. If you have received therapy for any reason, did you intentionally hurt yourself after
your treatment ended?
o Yes, I did intentionally hurt myself after treatment
o No, I completely stopped intentionally hurting myself after receiving treatment
o I have seen multiple therapists about intentionally hurting myself and some
helped me and some did not
36. In your opinion, how helpful was therapy in helping you to stop
intentionally hurting yourself?
o Very helpful
o Helpful
o Somewhat helpful
o Not at all helpful
37. What in your experience with therapy (even if your experience with intentionally hurting
yourself was not the focus of your therapy) has been most helpful in helping you to
understand or control intentionally hurting yourself?
L. Personal Reflections and Advice

38. Looking back, how has your experience with intentionally hurting yourself impacted your
life, both positively and negatively? (Please check all that apply)
o I still cannot talk about it and sometimes even thinking about it is difficult
o The lasting marks / scars are constant reminders of a bad / rough time in my life
o I am now able to help others who intentionally hurt themselves
o In thinking / discussing my experience around intentionally hurting myself, I have
learned a lot about myself and because of it have mentally / emotionally grown
o My scars are my battle wounds - I made it through
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o Discussion of my experience around intentionally hurting myself has helped me

grow closer to the people I care about
o The remaining marks / scars are a source of embarrassment for me
o It really did not impact my life much at all
39. What do you think is important for people who want to understand and help those who
intentionally hurt themselves to know?
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! !
COPING WITH URGES

Coping with Self-injury Urges
“How long should you try? Until.”
List of coping strategies:
1. The 15-Minute Rule - Jim Rohn
2. Ride the Wave
3. Keep and Review a Log
4. Relaxation In this strategy guide, we share a number of helpful coping
5. Talking to someone strategies that have been found to be useful by others
6. Do a Creative Activity struggling with self-injury.
7. Listen to Music Often, recovery comes down to trying to cope moment-to-
8. Exercise moment with the urges to self-injure, the day-to-day struggles
9. Play or Cuddle with a Pet with difficult emotions, as well as improving overall wellbeing
in our lives. None of this is easy.
Many times you may feel very alone in this struggle.
But, a central message of SiOS is that: You are NOT alone.

The strategies we present are taken from individuals, like you,
who struggled with self-injury and who overcame it.
Not all the suggestions will fit for you and that’s okay.
It can help though to choose and try the ones that feel right to
you.
Please also check out the SiOS “Help and Recovery” and
“Resource” pages for more self-injury support and resources.
All information found on SiOS is provided for information and education purposes only. The information is not intended to substitute for the advice of a
physician or mental health professional. You should always consult your doctor for specific information on personal health matters, or other relevant
professionals to ensure that your own circumstances are considered. 80
! !
Strategy 1: The 15-Minute Rule Strategy 2: Ride the Wave
When you feel the urge to self-injure, instead of When coping with urges it can be helpful to become aware of
giving into the urge immediately, tell yourself that you how the urges start out and then become increasingly intense
will wait 15 minutes and set a timer. and, if resisted, they then decrease in intensity - just like a wave.
During those 15 minutes try some of the coping Many therapies for self-injury focus on learning techniques
techniques listed here. (such as those on this website), including: breathing, relaxation,
and mindfulness to help you to “ride the wave” of these urges.
After the time is up, how do you feel?
This way, you can learn that if you can ride it out it will decrease
Has the urge diminished? and pass.
Is it gone completely? This is why reading and thinking about the times when you have
NOT acted on the urge can be very helpful.
If it’s gone or smaller, make note of this.
It is a good idea to practice mindful breathing and the relaxation
and use them as tools to help you resist the urge and “ride the
wave”.
Caroline Kettlewell, in her story of recovery from self-injury,

stated:
“I stopped cutting because I always could have stopped cutting;

that’s the plain and inelegant truth. No matter how compelling
the urge, the act itself was always a choice. I had no power over
the urge, but the act itself was always a choice. I had no power
over the flood tide of emotions that drove me to that brink, but I
had the power to decide whether or not to step over. Eventually I
decided not to.”
! ! ! Caroline Kettlewell, Skin Game (p. 177)
! !
Strategy 3: Keep and Review a Log
Keep and review a log...and think about times you wanted to self-injure but didn’t...
It can be very helpful to keep a log of the times you did not self-injure even though you felt the urge.
This strategy requires that when you have the urge to self-injure, you look at your log and think about the
times you had urges as strong as (or even stronger!) than the urge you have now and you DID NOT ACT
ON IT.
Think about how you have resisted the urge before and you can again.
The urge to self-injure can be powerful, but everyone has experienced at least one time when they felt that
urge but did not self-injure (even if it was because you were surrounded by people and could not find a way
to be alone).
Keep a record of these times.

To do this, list the urge you felt, what brought it on, and the reasons why you did not self-injure.
Was there something in the environment that stopped you?
Was it something within you?
Perhaps something you did instead?
A combination of any number of these?

Recognize these times and give yourself a pat on the back.
Remember: you can resist the urge and you have in the past.
! !
Strategy 4: Relaxation
Slowly relaxing different parts of your body can be very helpful when resisting an urge to hurt yourself. People
who have self-injured often say that this type of activity can be very helpful in resisting urges and feeling
better.
We are developing an audio file you can download and play from your phone, iPod, MP3 player or computer
whenever you have an urge or need to relax. In the meantime, our website provides a link which directs you
to files you can download that walk you through some of these types of relaxation exercises. Please be sure
to check back on the SiOS website soon for updates!
Strategy 5: Talk to someone
Talking to someone can be very helpful when you are having an intense urge to self-injure. This can be
done in three ways:
1. Sharing your current urge to self-injure with another person and in order to not act on it. However,
this may be very difficult and you may not have told anyone about your self-injury. In that case, you can still
reach out to someone and talk to him/her about your intense and difficult emotions that are making you want to
self-injure even if you do not share your self-injury or your urge.
2. If it is too difficult to share these intense emotions, you can still reach out to someone and talk to
him/her. To distract yourself from your emotions and urges you can talk about other things. If you can’t reach
the first person you call, try someone else.It may be helpful to make a list of people who you can call close by
to remind you that there are others you can call.
3. If there is no one you can call, you can and should also go online to connect with others. For
instance, you can go on Facebook to talk to a friend or relative who is online. You can also try different
websites. If you go to a website about self-injury, it is important to recognize that some websites about self-
injury may have triggering content. However, there are some great websites which can be helpful. For instance,
Recover Your Life provides people who struggle with self-injury with a way to connect with others, including a
live chatroom, available at certain times in the day, and a very active message board. It may also be helpful to
find a local helpline (e.g., Kids Help Phone, Crisis Line) that you can call when you’re upset.
! !
Strategy 6: Do a creative activity Strategy 7: Listen to music!
You can sing, play an instrument, sketch, paint, But, avoid triggering music that you know will
sculpt, etc. worsen mood or that reminds you about self-
injury.
Some individuals say that being able to express
their intense emotions through a creative outlet can Listening to music, often played loudly, can provide
be helpful. some relief.
Others find that a creative activity can distract or is Also, many people find that dancing vigorously to
so involving that it helps to not act on the urge to the music can be especially helpful.
self-injure.
Strategy 8: Exercise! Strategy 9: Play/cuddle with a pet
Exercise intensely to raise your heart rate. You Cuddling with a pet can be very soothing and
can run, jump, climb stairs, cycle, walk uphill, comforting. Many people find that cuddling with a
dance, fast pushups, use weights (if handy), etc. favorite pet helps to avoid acting on an urge to self-
injure.
Exercising vigorously to raise your heart rate has
been shown in research to be effective for some This can also be done together with other
people as a way to manage urges to self-injure. strategies. For example, waiting the 15-minutes and
using the 15-minute wait-rule with cuddling a pet
It is important that the exercise be intense and lasts can increase the effectiveness of both strategies.
until the urge passes (breathing hard and sweating).
Intense exercise may therefore serve as a healthy
substitution for self-injury and coping with intense,
difficult emotions.
www.twloha.com
It started with a story.

Our founder, Jamie Tworkowski, didn’t set out to start a nonprofit organization. All he wanted to
do was help a friend and tell her story. When Jamie met Renee Yohe, she was struggling with
addiction, depression, self-injury, and suicidal thoughts. He wrote about the five days he spent
with her before she entered a treatment center, and he sold T-shirts to help cover the cost. When
she entered treatment, he posted the story on MySpace to give it a home. The name of the story
was “To Write Love on Her Arms.”
85
86
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My Name:
My best relationship:
Me2 My best friend: When I’m alone, I like to:
The think I like to do with my

friends the most:
Something I’m good at:
Three most important people in my

life (real):
Where I feel the best (location):
Three most important people in my

life (fictional): Draw yourself as these others see
Where I feel
the worst: you:
Your parents…
When I feel the

best:
When I feel the worst:
Others in this group…
Something that makes me feel best about myself:
What makes me feel worst about myself:
©Copyright, 2015 Groupworks, Inc.
88
My Name: My greatest fear:
A Name I’d Like to have:
Me The coolest
thing in my
bedroom:
The famous person who would play me in a
movie about my life:
My favorite song:
Something I wish my mom wouldn’t say:
Something I like about my dad:

One Food I Know How to Cook:
Draw your own personal symbol:

The coolest Favorite Drink:
person I know:
Favorite Place The funnest

to go on thing I’ve
Vacation: done in the
last year:
Something that makes

me Happy:
If I were a food, I’d be…
The best day of my life:
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What is Non-Suicidal Self-Injury?

o Broad class of behaviors defined by direct,

o Self-injury typically refers to a variety of

o Others at-risk for this:

Population Prevalence Rate Source

Pre-Adolescents 7% Lloyd Richardson (2010)

18-25 Year Olds 13-45% (Lifetime) Rodham & Hawton (2009)

Older Adol/College Age 12-35% (Lifetime) Miller, Rathus & Linehan

Adults-Community Sample 6% (Lifetime) Klonsky (2011)

Adults-Clinical Sample 20% (Lifetime) Briere & Gil (1998)

Males 9% Laye-Gindhu & Schonert-

Females 20% Laye-Gindhu & Schonert-

o Klonsky (2007) looked o Walsh & Frost (2005) in

As cited in Walsh, 2012

o NSSI can last for weeks, months, or years

C. The intentional self-injury is associated with at least one of the

o Constant use of wristbands

What Other Signs Do

o More likely to report

oNew research shows

o People who engage o When the pain

Adapted from Nillumbik Community Health Service, 2012

o Regulating the External Environment

o Walsh (2006) argues that the relationship with

o Brunner et al. (2007) reported that 9th graders

o Ross, Heath, & Toste (2009) found that regardless of

Cited in Muelenkamp & Brausch (2012)

o Body image significantly mediated the relationship

Increased emotional distress

o Physical & Sexual Trauma

o Community Violence o School Violence

o Serotonin-Inconsistent, deficiency more associated

o Victor, Glenn & Klonsky (2012)

NSSI & Suicide

o NSSI typically considered:

Muelenkamp & Kerr, 2010

Characteristic NSSI Suicide Attempt

Intent/Purpose for Temporary Escape from Permanently terminate

Create Change in Self To Escape Unbearable

Characteristic NSSI Suicide Attempt

High, sometimes more

Characteristic NSSI Suicide Attempt

Number of Methods Multiple Methods Single Methods used

Characteristic NSSI Suicide Attempt

Cognitive Status Distressed yet

5 Questions Every Therapist

o Everyone presenting for mental health services

The Non-Suicidal Self-Injury Assessment

Once the presence of

1. What are the Functions of the Behavior?

o To Deal with Anger

o When was the most