Non-Suicidal Self-Injury

Reader’s Question

Every time I pick up a knife (sharp or blunt) I have to cut myself in the gut with it. Not hard enough to draw blood, but just hard enough to feel a tiny bit of pain… I’m not crazy or anything, I think it’s just a habit.

Psychologist’s Reply

You’re right, you’re not crazy. However, what you describe could be something that is serious. This could be behavior that we call Non Suicidal Self-Injury or NSSI. This behavior has been called many things over the years, such as self-mutilation, parasuicide, or cutting, and it has often been confused for suicidal gesturing or suicidal attempts. Incidence rates for NSSI are typically higher in adolescence, but it is present in the adult population as well. Cutting tends to be the most popular but other methods include burning, scratching, hitting oneself, deliberately interfering with wounds healing and a list of many others. There is a wide diversity of people who engage in NSSI; the rate of males reporting it is quickly caching up to the rates of females.

Understanding the motivation behind NNSI is important not only to understanding why these behaviors happen but also to understanding how it is treated. Let’s talk about the reasons why for a second because there is plenty of myth, stigma and misconception around the issue.

The Affect Management Model of NSSI suggests that individuals self-harm as a way to manage intense negative emotions. What happens is that the person begins to experience bad emotions triggered by some negative event or thought, and the self-injury is used to cope or help them calm down. Many of my clients have used this method because they say it helps distract them from their emotional pain, brings back a sense of control, or provides a way to self-punish. The goal is very simple here: to change the way they feel. Some research even points to the fact that, when people cut or hurt themselves, the body generates endorphins in the brain that are soothing and calming. I’ve had few tell me this feeling can be “addicting” for them. For most of these people treatment can help by focusing on building ways to manage feelings without self-injury.

The Affect Generation/Dissociation Model of NSSI suggests that those who self-injure are looking to find some ways to generate emotion because they are feeling numb or are in a dissociative or depersonalized state. These individuals use NSSI to actually help bring on emotion. Some of my clients will tell me that they cut or burn to “feel alive” or just to feel something at all. Sometimes negative events will cause people to shut down emotionally or disassociate from the experience as a way to protect themselves from those intense feelings. Interventions that bring about mindfulness and help reconnect the person to themselves and their surroundings tend to help.

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Finally, the Social/Communication Model of NSSI looks to explain NSSI as a way to communicate distress to others or rally some social support for their distress. Often this is mistaken as “attention seeking” behavior (which carries a very negative stigma) and then ignored or minimized by those the person is actually wanting to communicate to. Individuals are often labeled as manipulative because of it. The truth is the goal of the self-injury is to find support and connect with it. Helping individuals find a way to better voice their distress and communicate to people who care without burning those bridges is important. Helping them better understand the negative impact NSSI has on those relationships is important too. I have found in my own research that this model of NSSI is also relevant in individuals who attempt suicide.

There are many other reasons why people may use NSSI, and even a combination of the three models is common.

On another note, it is very important to understand NSSI’s connection to suicide. There is a strong relationship between the two, but they are different. What makes NSSI so different is that, unlike suicidal behaviors, there is no intent to die. NSSI is predominately a way to cope, albeit in a not so productive way. However, about 40% of those who self-injure have seriously considered suicide. Some of them have gone on to attempt suicide. We must be careful not to mistake someone building up to a suicide attempt as NSSI.

One of the biggest problems with NNSI is not just the behaviors, but the fact that NSSI is not understood well by everyone else. This lack of education creates stigma and fears about NSSI. This tends to keep those who self-injure in the dark and out of treatment. In addition, other behaviors tend to get labeled as NSSI even when they are not. NSSI are behaviors that are typically not “socially sanctioned” such as cutting or burning. So, getting a tattoo, even a full sleeve, is not NNSI. Nor is body piercing or spacers in one’s earlobes. These behaviors are typically seen as artistic expression or even fashion. Having focused on creative personality types and artists in my own practice, I see these behaviors as quite different.

In conclusion, if you do find yourself engaging in true NSSI, I think it is critical to seek help. Often NSSI does not help an individual feel better for long and they soon find themselves right back to those self-injury behaviors again. After a while, many find that the scars of repeated self-injury get more difficult to hide, make their body unappealing to themselves, and push others away leaving, the self-injurer feeling misunderstood or alone. There are other solutions, and many of my clients get better. Finding the right therapist who is knowledgeable about NSSI is critical. Finding new ways to cope that lead to feeling better long term is well within reach.