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Welcome to SPRC’s Research to
Practice Webinar on
Understanding Nonsuicidal Self-Injury in
Suicide Prevention
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Understanding Nonsuicidal
Self-Injury in
Suicide Prevention
Morton M. Silverman, M.D.
Suicide Prevention Resource Center
Barent Walsh, Ph.D.
The Bridge of Central Massachusetts
4
Nonsuicidal Self-Injury:
An Introduction and Perspective
Morton M. Silverman, M.D.
Senior Advisor
Suicide Prevention Resource Center
Newton, MA
SPRC R2P Webinar
July 27, 2010
A Perspective
Terms in the Literature:
• Self-Harming Behaviors (SHB)
• Self-Mutilative Behaviors (SMB)
• Self-Injurious Behaviors (SIB)
SIB = refers to a broad class of behaviors in which an
individual directly and deliberately causes harm
to him/herself
Self-Injurious Behaviors (SIB)
2 Types of SIB:
• Nonsuicidal Self-Injury (NSSI)
• Suicide Attempts (SA)
NSSI = direct, deliberate destruction of one’s own
body tissue in the absence of intent to die
SA = direct efforts to intentionally end one’s
own life
Associations and Correlations,
but not Necessarily Causations
• There are theoretical, methodological, and
clinical differences among various forms of SIB
• However - these behaviors are related,
interactive, and can co-occur within
individuals
• Hence - these behaviors may well lie along a
continuum of self-harming behaviors
Some Similar Risk Correlates
•
•
•
•
•
Emotional regulation skills
Problem-solving skills
Communication problems
Impulsivity
Unstable interpersonal relationships
The Relationships between
NSSI and Suicide Attempts (SA)
• NSSI is a risk factor for subsequent suicidal
behaviors
• NSSI is similar to suicidal ideation in conferring
increased risk for SA
• NSSI can be mistaken for SA - and vice versa
• Some individuals report both NSSI and SA
• NSSI and SA commonly co-occur - especially in
adolescents
Relevance to Joiner’s Theory
• Joiner’s Theory suggests that habituation to
fear and physical pain, such as that associated
with suicidality, increases the desire and the
capability to engage in lethal self-injurious
behaviors
• Hence….repeated episodes of NSSI may
increase the risk for subsequent SAs and death
by suicide
Joiner TE (2005). Why People Die by Suicide. MA: Harvard University Press
Implications for Suicide
Prevention
• The prevention of SIB (NSSI and SA) addresses
similar psychological, emotional, cognitive,
and interpersonal factors
• Plus…..by preventing NSSI, the expected
outcome would be a reduction in subsequent
suicidality
Goals of This Webinar
• What is NSSI?
- similarities/differences to SA
• How is NSSI a risk factor for suicide?
• How do you intervene with NSSI?
• How do you prevent NSSI in high schools?
• How do you evaluate prevention outcomes?
Understanding Nonsuicidal SelfInjury in Suicide Prevention
Barent Walsh, Ph.D.
Executive Director
The Bridge of Central Massachusetts, Inc.
4 Mann Street
Worcester, MA 01602
Phone: 508-755-0333
email: barryw@thebridgecm.org
Thanks to:
• Jennifer Muehlenkamp, PhD, University of
Wisconsin-Eau Claire
• Candice Porter, MSW, Screening for Mental Health
-- for their contributions to the High School
Prevention Program
And to:
• Morton Silverman, M.D.
• Tiffany Kim & Xan Young, Suicide Prevention
Resource Center
-- for their contributions to this presentation…
Differentiating Suicide
from NSSI
Suicidal Behavior
NSSI
Prevalence
In U.S., 10 deaths by
suicide per 100,000 in
population
Unclear; estimates
from 400 to 1400 per
100,000
Intent
Permanently end
psychological pain;
terminate consciousness
Temporarily modify
emotional distress;
effect change in
others
Lethality of
Method
High lethality: gunshot,
hanging, O.D., jumping,
ingesting poison
Low lethality: cutting,
self-hitting, burning,
picking, abrading
Differentiating Suicide
from NSSI
Suicidal Behavior
NSSI
Cutting as a
method for
suicide vs.
NSSI
Almost no one dies by cutting:
All ages: .2% of suicides die by
cutting; For 15-24 year olds:
.6%; For 25-34 year olds: 1.5%
Cutting is the most
common NSSI method
almost universally in
both community &
clinical samples
Frequency
Low rate behavior even in
severely mentally ill persons
Frequently high rate:
scores of episodes per
person
Number of
methods
Repeat attempters generally
employ one method, often
overdose
In both community &
clinical samples, most
use multiple methods;
e.g. Whitlock (2008)
78%
Differentiating Suicide
from NSSI
Suicidal Behavior
Ideation
Suicidal ideation
predominates; less
positive Reasons for
Living and Attraction to
Life (Muehlenkamp 2010)
NSSI
Suicidal ideation
infrequent;
concerning when
present; more
positive RFL and AL
Cognition & Affect Helplessness and
hopelessness
predominate; poor
problem solving
Helplessness and
hopelessness less
likely as long as NSSI
“works”; more intact
problem solving
Aftermath
Immediate relief;
reduction in negative
affect
Continued despair; often
high lethality
Differentiating Suicide
from NSSI
Reaction of others
Suicidal Behavior
NSSI
Most others express
concern and support;
move towards
protection
Ongoing NSSI may be
condemned, judged
negatively; therapyinterfering behaviors
are common (aka
counter-transference)
Restriction of means? Often an important
preventive
intervention
Often ill-advised,
counterproductive
Cautionary Notes: SelfInjury vs. Suicidal Behavior
• While self-injury is generally not about ending
one’s life, NSSI is a risk factor for suicidal
behavior.
• It is important to emphasize that while the
behaviors are distinct, both can occur within
the same individual.
The Relationship between
Suicide Attempts & NSSI
• NSSI is associated with Suicide Attempt Risk
when the following are present:
-
Higher levels of suicidal ideation
Severity of depression
Diagnosis of Borderline Personality Disorder
Impulsivity
Greater levels of negative affect
Apathy & hopelessness
Self-derogation/lack of self-acceptance
Brausch & Gutierrez (2009); Muehlenkamp (2010)
Relationship Between NSSI
and Suicide Attempts
What to Watch For…
• Severity and duration of NSSI
• NSSI becoming less effective in reducing emotional
distress
• Worsening mental health symptoms
Protective Factors
• Family connectedness, support
• Peer social support
Brausch & Gutierrez (2009) Muehlenkamp (2010)
More on the Relationship
between Suicide Attempts
and NSSI
Klonsky (2010) reported in a recent study of 428
high school students:
• NSSI - 6%
• Suicide Ideation - 17%
• Attempted Suicide - 3%
Rates of attempted suicide among those who had:
• NSSI
• Suicide Ideation
27%
18%
Relationship to
Attempted Suicide
Adolescent inpatients (n = 171)
•
•
•
•
•
•
Suicide Ideation
NSSI
Borderline Personality
Emotion Dysregulation
Impulsivity
Loneliness
Klonsky (2010)
.55
.50
.39
.34
.11
.09
Conclusion re:
Suicide and NSSI
NSSI is substantially different from suicide, yet
NSSI is a strong risk factor for suicide
• Good clinical practice suggests:
- Understand, manage, & treat differentially
- Carefully cross-monitor; assess interdependently
- Intervene early with NSSI to prevent emergence of
suicidality
NSSI Demographics
in the U.S.
• In community samples, a range of 6 to 25 % of youth
report self-injuring at least once
• In clinical samples, more females report NSSI than
males; In community samples, no gender difference
• Age of onset for the majority is 13 to 15
• NSSI may be more common among Caucasians &
GLBTQ youth (Nixon & Heath, 2008)
• Females may be more likely to cut or pick; Males may
prefer self-hitting, punching walls (community
sample, Whitlock 2008)
More U.S. Demographics
• Data from the 2007 Massachusetts Youth Risk
Behavior Survey (YRBS) indicated that 17% of high
school students and 16% of middle school students
reported having self-injured during the past year.
• Also, a recent study from Cornell and Princeton
Universities, using a sample of almost 3000 students,
found that 17% indicated having self-injured
(Whitlock et al. 2006b).
-- And in a follow-up study involving 8 colleges and more than
11,000 students, Whitlock (2008) found that 15.3% reported
some NSSI lifetime; 29.4% reported more than 10 episodes
Therefore….
Given the increased prevalence of NSSI in the
general population…
And its role as a risk factor for subsequent
suicidality….
We developed a self-injury prevention program
for high school staff and students
Program Components
•
•
•
•
•
•
Signs of Self-Injury DVD (SOSI)
Self-assessment form for students
Lesson plan and discussion guidelines for teachers
Lecture for staff training
Guidelines for planning a parent training
Templates for educational and communication
materials for staff, parents, and students
• Self-Injurious Thoughts and Behaviors Interview
(SITBI) assessment forms for school clinicians (Nock
et al. 2007)
Program Goals
• Decrease NSSI by teaching students more adaptive
coping skills
• Decrease self-injury by educating students and the
school community about risk factors, clinical
implications, and outcomes associated with selfinjury.
• Encourage help-seeking among students – either for
themselves or on behalf of a friend.
• Help school staff make the key distinction between
self-injury and suicide.
Program Goals
(continued)
• Engage parents and school staff as partners in
prevention - teach them to identify and respond to
signs of self-injury.
• Encourage schools to develop a school protocol for
responding to self-injury that is strategic,
compassionate, and effective.
EDUCATION about Self-Injury
DVD (2 chapters)
Discussion Guide
•Emphasizes NSSI is treatable
Provides basic NSSI info
•Models appropriate responses
Provides discussion guidelines
•Encourages help seeking
BEHAVIOR
• Acknowledge (the signs)
• Care (express concern)
• Tell (a trusted adult)
RISK ASSESSMENT
• Student assessment tool
• Clinician assessment tool (SITBI)
•Referral to Treatment as needed
“Signs of Self-Injury”
DVD
• The 29 minute DVD is the main teaching tool.
• Includes 2 chapters - 1 for students and 1 for staff.
• Student chapter includes:
- 3 dramatizations of students responding to NSSI with a
friend and with a school guidance counselor
- 2 demonstrate help-seeking behavior; 1 reviews how to
avoid social contagion
- a personal testimonial from a person who has recovered
from self-injury (not an actor)
• The DVD uses teen actors who model appropriate
support and help-seeking behaviors (ACT message).
The “Signs of Self-Injury: ACT®
to Prevent Self-Injury
Prevention Program”
The DVD employs the Acronym ACT
> Acknowledge that your friend has a problem
and that self-injury is serious.
> Care enough to let your friend know you want
to help.
> Tell a trusted adult about the self-injury.
Implementing the
Program for Students
The program for students takes about 60 minutes.
Some schools choose to employ 2 class periods or over
2 days. The steps include:
•
•
•
•
•
Introduction (5 minutes)
DVD (18 Minutes)
Discussion (20-30 minutes)
Student Self-Assessment (10 minutes)
Help-Seeking; Students complete a Response Card which
allows them to request to speak with someone after the
program (5 minutes)
DVD Program Continued
Staff chapter includes:
• clinical information about NSSI
• response guidelines, recommending the use of a
“low key dispassionate demeanor”
• A DVD chapter in which a guidance counselor
demonstrates appropriate responses
• Interviews with NSSI experts and school personnel
who have dealt with NSSI in their schools
• Guidelines for preventing social contagion of NSSI
Implementing the Program
For Staff
Staff training takes about 1 – 1.5 hours. It includes:
• Introduction; what SOSI is, who it targets; Reviewing
myths vs. facts of NSSI
• Viewing both chapters of the DVD, staff version & student
version (29 minutes)
• Reviewing the teaching points of the video
• Developing a staff team to respond to NSSI
• Reviewing a school protocol for handling students who
disclose NSSI
• Reviewing school and community health resources
• Identify a point person that training participants can
contact regarding future questions
SOSI Outcome Data
• 5 Schools; 282 students total
• Pre-Assessment, Program, Post-Assessment
• Assessment Tools
- SITBI for NSSI thoughts, behaviors
New Instrument that measures:
- Knowledge of NSSI (11 items; = .93)
- Attitudes
• Discomfort with NSSI ( = .83)
• Avoidance of peer NSSI ( = .77)
• Approach/Helping Desires ( = .85)
- Help-seeking behaviors
Muehlenkamp et al. (2009)
Outcomes for SOSI
Program Evaluation
9
8
7
6
5
PRE
4
3
2
POST
p < .001
p < .001
p < .08
1
0
Knowledge Discomfort Avoidance Help Desire NSSI Act
SOSI Outcomes Conclusions
• Improved attitudes in students towards acceptance
& helping
• No iatrogenic effects reported
• Help seeking behaviors increased (but not
significantly)
• Feasibility Data = Very positive from school staff
• NSSI acts declined (but not significantly)
• Program has initial promise; more research needed
For the full report, see: Muehlenkamp, J.J., Walsh, B.W. & McDade, M. (2009).
Preventing non-suicidal self-injury in adolescents. Journal of Youth and
Adolescence, 39, 306-314.
For More Information on
the SOSI Prevention
Program
Candice Porter at Screening for Mental Health,
Wellesley, MA.
E-mail:
cporter@MENTALHEALTHSCREENING.ORG
Phone: 781-239-0071
For questions and feedback regarding
the webinar, please contact:
Xan Young
Project Director, Training Institute
Suicide Prevention Resource Center, EDC
xyoung@edc.org
Tiffany Kim
Project Coordinator, Training Institute
Suicide Prevention Resource Center, EDC
tkim@edc.org
General References
re: NSSI
Alderman, T. (1997). The scarred soul: Understanding and ending self-inflicted
violence. Oakland, CA: New Harbinger Press.
Beck, J.S. (1995). Cognitive therapy, basics and beyond. New York: Guilford
Press.
Bohus, M., Limberger, M., et al. (2000). Pain perception during self-reported
distress and calmness in patients with
borderline personality disorder and self-mutilating behavior, Psychiatry
Research, 95, 251-260.
Foa, E.B., Keane, T.M. & Friedman, M.J. (Eds.). (2000). Effective treatments for
PTSD. New York: Guilford Press.
Gratz, K.L. & Chapman, A.L. (2009). Freedom from self-harm: Overcoming selfinjury with skills from DBT and other treatments. Oakland, CA: New
Harbinger.
Hayes, S.C., Follette, V.M. & Linehan, M.M. (Eds). (2004). Mindfulness and
acceptance. New York: Guilford Press.
Hollander, M. (2008). Helping teens who cut. New York: Guilford.
Hyman, J. (1999). Women living with self-injury. Philadelphia: Temple
University Press.
General References
re: NSSI
Joiner. T. (2007). Why people die by suicide. Cambridge, MA: Harvard
University Press.
Joiner, T. (2010). Myths about suicide. Cambridge, MA: Harvard University
Press.
Keuthen, N.J., Stein, D.J. & Christenson, G.A. (2001). Help for hair pullers,
Understanding and coping with trichotillomania. Oakland, CA: Harbinger
Publications.
Kettlewell, C. (1999). Skin game: A Cutter’s Memoir. New York: St. Martin’s
Press.
Klonsky, D. E. (2007). The functions of deliberate self-injury: A review of the
evidence. Clinical Psychology Review, 27, 226-239.
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personality disorder. New York: Guilford Press.
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personality disorder. Guilford.
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with suicidal adolescents. Guilford.
General References
re: NSSI
Muehlenkamp, J. J. (2006). Empirically supported treatments and general
therapy guidelines for non-suicidal self-injury. Journal of Mental Health
Counseling, 28, 166-185.
Nhat Hanh, T. (1975). The miracle of mindfulness. Boston, MA: Beacon Press.
Nixon, M.K. & Heath, N.L. (2008). Self-injury in youth. New York: Routledge.
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(3), 309-317.
Nock, M.K. & Kessler, R.C. (2006). Prevalence of and risk factors for suicide
attempts versus suicide gestures: Analysis of the National Comorbidity
study. Journal of Abnormal Psychology, 115(3), 616-623.
Nock, M. K. & Prinstein, M. J. (2004). A functional approach to the
assessment of self-mutilative behavior. Journal of Consulting and Clinical
Psychology, 72(5), 885-890.
Segal, Z.V., Williams, J.M.G. & Teasdale, J.D. (2002). Mindfulness-based
cognitive therapy for depression. New York: Guilford.
Shneidman, E.S. (1985). Definition of suicide. New York: John Wiley & Sons.
General References
re: NSSI
Walsh, B. & Doerfler, L. (2009). Residential treatment of self-injury. In Nock,
M. (Editor). Understanding non-suicidal self-injury: Origins, assessment,
and treatment. Washington, DC: American Psychological Association.
Walsh, Barent (2007). Clinical assessment of self-injury: A practical guide.
Journal of Clinical Psychology: In Session, 63, 1057-1068.
Walsh, B. (2006). Treating self-injury: A practical guide. New York: Guilford.
Walsh, B. & Rosen, P. (1985). Self-mutilation and contagion: An empirical test.
American Journal of Psychiatry, 142, 119-120.
Walsh, B. & Rosen, P. (1988). Self-mutilation: Theory, research and treatment.
New York: Guilford Press.
Whitlock, J., Eckenrode, J., & Silverman, D. (2006b). Self-injurious behaviors in
a college population. Pediatrics, 117(6), 1939-1948.
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The internet and adolescent self-injury. Developmental Psychology, 42(3),
1-11.
References re: the Relationship
Between Suicide and NSSI &
Demographics of NSSI
Berman, A.L., Jobes, D.A. & Silverman, M.M. (2006). Adolescent suicide:
Assessment and Intervention (2nd ed.) Washington, DC: American
Psychological Association
Brausch, A. M. & Gutierrez, P. M. (2009). Differences in non-suicidal self-injury
an suicide attempts in adolescents. Journal of Youth and Adolescents, 39
(3), 233-242.
Centers for Disease Control and Prevention (2009). Web-based Injury
Statistics Query and Reporting System (WISQARS). Available from
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youth: The essential guide to assessment and intervention. New York:
Routledge.
Klonsky, E.D. (2010). The Relationship Between Non-Suicidal Self-Injury and
Attempted Suicide in Three Samples. Panel session at the Annual meeting
of the American Association of Suicidology, Orlando, FL.
References re: the Relationship
Between Suicide and NSSI &
Demographics of NSSI
Klonsky, E.D. & Muehlenkamp, J.J. (2007). Non-suicidal self-injury: A research
review for the practitioner. Journal of Clinical Psychology/ In session, 63,
1045-1056.
Massachusetts Department of Elementary and Secondary Education (2008).
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available at: http://www.doe.mass.edu/cnp/hprograms/yrbs
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How non-suicidal self-injury and suicide attempts differ. The Prevention
Researcher, Volume 17(1), 8-10.
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adolescents who engage in non-suicidal self-injury. Archives of Suicide
Research, 11, 69-82.
Muehlenkamp, J.J. (April 2010). Evidence-based approaches to nonsuicidal
self-injury. Day long pre-conference workshop with Barent Walsh. Annual
meeting of the American Association of Suicidology, Orlando, FL.
References re: the Relationship
Between Suicide and NSSI &
Demographics of NSSI
Nock, M.K., Joiner, T.E., Gordon, K.H., Lloyd-Richardson, E. & Prinstein, M.
(2006). Nonsuicidal self-injury among adolescents: Diagnostic correlates
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Psychological Association.
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Walsh, B.W. (2006). Treating self-injury: A practical guide. New York: Guilford
Press.
Whitlock, J., Eckenrode, J., & Silverman, D. (2006b). Self-injurious behaviors in
a college population. Pediatrics, 117(6), 1939-1948.