Self-harm, also known as Non-Suicidal Self-Injury (NSSI), is a serious public health concern for teens and young adults. Although distinct from suicidality per se, it is typically associated with suicidal ideation, anxiety, and depression, all of which have dramatically increased in this population over the last decade. Self-injurious behavior can have numerous causes/functions, but it is essentially a mental health disorder related to difficulties with emotional regulation that often arises as a way to cope with trauma. It typically begins in early to mid-adolescence, between the ages of 12 and 16, a developmental stage that is emotionally tumultuous for many young people.
Each year on March 1 mental health professionals and other youth advocates recognize Self-Injury Awareness Day (also known as Self-Harm Awareness Day) as part of a month-long global awareness campaign to educate both the public and health professionals, and to help those struggling with this behavior to access mental health treatment. Some people wear an orange ribbon or write “love” or draw a butterfly on their arms to signal awareness and support. March, therefore, is a good time for school districts to update SEL and other mental health curricula to include information about the causes and treatments for NSSI, and to help both staff and parents understand the signs and symptoms to look for.
What is NSSI and Why Is It a Major Mental Health Concern for Adolescents?
Non-suicidal self-injury (NSSI) is defined as direct and intentional self-inflicted bodily pain or harm that includes behaviors such as cutting, burning, scratching, biting, head-banging, and skin-picking. Although individuals who engage in self-harm might also have suicidal thoughts, in the moment the behavior itself does not have suicidal intent, and socially acceptable forms of body modification such as tattoos and piercings are excluded from the definition. NSSI is a major health concern for adolescents because of direct tissue damage and other bodily injuries (e.g., risk of infection), but also because it is so closely associated with higher levels of depression, anxiety, and suicidality.
Another form of NSSI, known as digital self-harm, is defined as the anonymous posting, sending, or sharing of hurtful content online about oneself. Results of a recent study showed that “approximately 9 percent of adolescents reported that they had anonymously posted something online about themselves that was mean, while about 5 percent said they had anonymously cyberbullied themselves …Most pertinent is the finding that those engaged in digital self-harm were between five and seven times more likely to have considered suicide and between nine and fifteen times more likely to have attempted to end their life.”
To say the least, many adults find it puzzling that individuals deliberately engage in behaviors to damage themselves physically and/or emotionally. A recent Psychology Today article neatly summarized four categories of precipitating factors:
- Some individuals engage in self-harm to feel pain that can counteract the sense of being emotionally numb or dissociated, both of which are coping strategies frequently used by those who have experienced abuse or other kinds of trauma. NSSI is a way to feel something.
- Some individuals who feel guilty or unworthy engage in self-harm as a form of punishment, to relieve them of their guilt. The inability to recognize one’s inherent worthiness can stem from adverse childhood experiences such as bullying, abandonment, abuse, and other traumas that lead individuals to conclude that they are just not good enough.
- Others use self-harm to distract from unwanted thoughts and feelings such as loneliness, anger, or depression. These individuals have difficulty tolerating painful emotions and memories and seek to avoid them because they have not developed healthy distress tolerance skills.
- Still others use NSSI as a form of emotional regulation when they cannot cope with or understand a situation. Self-harm appears to function like a release valve, but the relief is only temporary and is often followed by feelings of guilt and shame, thus contributing to a continuing cycle of self-harm and other mental health symptoms.
It can be difficult to detect when adolescents are hurting themselves since they frequently go to great lengths to hide their behavior. Concerned adults and peers should certainly watch for fresh cuts and scratches, bite marks, and burns, but also pay attention to unexplained scars, bruises, and bald patches. Youngsters who are self-harming might seem especially accident-prone or might wear long sleeves and other concealing clothing even in warm weather to hide fresh injuries or scars. They might be found carrying sharp objects without any apparent reason and might prefer long stretches of time spent alone. Youth at risk for self-harm may also show signs of depression or emotional unpredictability, making comments about a sense of hopelessness or worthlessness.
Social Media and Self-Harm
As with most things in today’s world, the question arises as to what role social media plays in the youth mental health epidemic, and in fostering self-harm per se. While the research is far from definitive in this area, clearly anything that contributes to comparing oneself negatively to others and/or that encourages unhealthy or risky behaviors (think TikTok challenges) can be problematic. Girls and young women are especially vulnerable to self-criticism and body image distortions based on what is portrayed in the media as the desirable “look” or body type, but research has yet to find a direct link between exposure to online content and youth mental health concerns that can universally be applied to all teens. Commonly, as with all mental health disorders, the factors contributing to depression, anxiety, suicidality, and NSSI vary from child to child, and must be teased out via a thorough mental health assessment. Experts have also noted that it is important to consider how “screen time” interferes with other healthy behaviors such as sleep, exercise, and in-person social interactions, and not just to the effects of exposure to online content and long stretches of time spent in the virtual world.
That said, websites that glorify NSSI, disordered eating patterns, and suicidality clearly exist, and teens are finding them. As reported by the University of Georgia in late 2021, “researchers found that posts with hashtags related to self-injury rose from between 58,000 to 68,000 at the start of 2018 to more than 110,000 in December.” With respect to the accessibility of these posts, the lead author of the study, Professor Amanda Giordano, wrote “I jumped on Instagram yesterday and wanted to see how fast I could get to a graphic image with blood, obvious self-harm or a weapon involved. It took me about a minute and a half.” These online forums can provide both validation and encouragement for teens engaging in these behaviors, while offering tips about where and how to injure oneself to avoid detection and how to care for their injuries.
While most teens (99%) do not visit sites that promote self-harm, “research suggests that youth who have visited self-harm and suicide websites are 11 times more likely to have thought about hurting themselves, compared to youth who have not visited such websites. Youth who visit such sites are also more likely to report a history of physical or sexual abuse, substance use, or delinquent behavior.”
What Research Reveals About NSSI Prevalence and Contributing Factors
A meta-analysis of 172 self-harm data sets collected from 1990 through 2015 was published in 2018. The analysis included data for 597,548 participants from 41 countries and revealed an overall lifetime prevalence of NSSI of 16.9% with rates increasing from 1990 to 2015. Girls were more likely than boys to self-harm, and the mean age of onset was 13 years. Cutting was the most common type of behavior reported (45%), with 47% of participants reporting only 1 or 2 episodes of self-harm. The most frequent reason given was relief from thoughts or feelings. Slightly more than half of the individuals sought help, although the help was most often from a friend rather than a healthcare professional or other adult. Suicidal ideation and attempts were significantly higher in adolescents who engaged in more frequent self-harm behavior.
A US-based study published in 2015 used the CDC’s Youth Risk Behavior Surveillance System data to estimate the prevalence of self-injury and the factors potentially associated with it. High school boys (32,150) and girls (32,521) in 11 states were included in the study. The percentage of boys reporting NSSI in the prior 12 months ranged from 6.4% (Delaware) to 14.8% (Nevada), while the rates for girls varied from 17.7% (Delaware) to 30.8% (Idaho). Rates declined with age and varied by race and ethnicity.
A more recent study (2022) that followed a non-clinical sample of over 4,000 American students from 7th to 10th grades found that girls were almost twice as likely as boys to have engaged in NSSI in the past 12 months (8.2% vs 4.8%). Based on prior research that had identified improving “connectedness” as a way to reduce suicidality and NSSI among youth, these researchers sought to unravel the protective factors associated with positive parent, peer, and school relationships, and to determine differences between girls and boys. They found that positive parent-family connectedness was the most salient factor associated with reduced self-harm behaviors for all adolescents, followed by school connectedness. Student-perceived school connectedness was found to be indirectly associated with NSSI through bullying victimization and depressive symptoms, although for boys, being bullied in the 7th grade was found to be a direct predictor of NSSI three years later. For girls, parent-family connectedness and depressive symptoms proved to be important direct predictors of NSSI.
The researchers hypothesize that bullying victimization and depressive symptoms might have a direct connection to NSSI because “both involve significant negative affect and adolescents who practice NSSI report that this reduces the intensity of negative affect.” The implication of these findings for school districts is that interventions that target depressive symptoms in girls and bully victimization of boys might help to reduce NSSI among their students.
Evidence-Based Mental Health Treatments are Available to Help
As alarming as NSSI behavior is, it is important to note that there are successful treatments and interventions to reduce and eliminate self-harming behaviors. Perhaps the best known and most extensively researched is Dialectical Behavior Therapy (DBT). It was described by authors of a 2018 study published in the Jama Psychiatry journal as “the best tool we have” as compared with other more generalized therapies.
DBT is a comprehensive clinical protocol created by Marsha Linehan, PhD that was introduced in her groundbreaking book published in 1993. It was designed to treat chronically suicidal and self-injuring clients, many of whom met criteria for both borderline personality disorder and trauma (PTSD), but since then it has been highly researched and successfully expanded to many different clinical populations. The full treatment program includes individual therapy, DBT skills training groups, and telephone coaching, and lasts from 6 months to 1 year minimally. Research has demonstrated that the DBT skills training component is itself an “active” ingredient of the treatment program and this component has been successfully adapted to many clinical and educational settings.
The treatment model is based on the combination of Eastern philosophies that promote a dialectical stance, acceptance, and mindfulness with the Western psychotherapy approach known as cognitive-behavior therapy. DBT skills are grouped into four training modules: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness. Mindfulness and Distress Tolerance are skills that focus heavily on the acceptance of “what is”, while Emotion Regulation and Interpersonal Effectiveness skills focus on changing bodily sensations and emotions, self-defeating thoughts, and ineffective and/or damaging interpersonal behaviors. Taken together, these skills help individuals to better regulate their emotions, to recognize internal states and tolerate distress, to focus attention, and to develop and sustain satisfying interpersonal relationships. For teens, parent involvement is critical, to provide validation and to support the use and practice of skills.
The use of medications continues to be controversial with young people, and there is no medication that can specifically “fix” suicidality, self-harm, or borderline personality disorder. However, since the success of DBT and other skill-building therapies is highly dependent on a child’s availability to learn and absorb new information, medication to reduce anxiety, lift depression, and/or improve attention/focus can be extremely helpful.
What Can Schools and Parents Do to Help?
There are several things to keep in mind when trying to reduce the prevalence of NSSI in a school population or when attempting to help a specific youngster already struggling with this behavior. The first, and perhaps the hardest to do, is to maintain a position of validation. Although it may feel like a fine line, it is possible to validate the feelings that give rise to self-destructive behavior while not validating or approving of the behavior itself. “Tell me what was happening right before you did this. You must have been feeling really awful and that there were no solutions to your problems,” followed by “what else have you tried to cope?” and “can we work together to find some other ways to cope?”
Districts can also:
- Emphasize to both school personnel and parents that the district’s SEL curriculum is a vital part of fostering positive mental health and thus academic achievement. It is not “fluff” or an unnecessary add-on. The emotion regulation and social skills taught in SEL classes are protective factors that can lessen the risk of developing self-harming behaviors. SEL and/or health curriculum should include modules about self-harm, suicidality, and eating disorders.
- Provide frequent staff and parent education about risk factors, including information about high-risk groups. For example, black adolescents are seeing huge spikes in suicide attempts, representing the fastest and sharpest upward curve of any ethnic group; LGBTQIA youth continue to rank high in self-harm and suicidal thoughts and behaviors.
- Consider that researchers hypothesize that youth who visit self-harm sites are looking for a sense of belonging and connection. Via parent-teacher and other school-based organizations districts can offer activities that foster school-student and family-school connectedness as a way to reduce the feelings of loneliness and disconnection that can give rise to self-harm.
- Emphasize to parents the importance of monitoring their children’s internet and social media usage and help them learn about the technologies available to do this. Offer ongoing education to students about how to use online resources responsibly, while at the same time initiating regular discussions about what they are seeing and responding to online.
- Offer regular professional development opportunities for school nurses and onsite mental health professionals about recognizing self-harm and about how to intervene in a validating, non-judgmental way.
- Ensure that MTSS programs include interventions that specifically target depressive symptoms in girls and bully victimization of boys as there appears to be a direct link between these factors and NSSI.
- Update referral lists and foster relationships with community organizations that offer mental health treatment for children and adolescents.
The staff of Effective School Solutions (ESS) know that self-harm and suicidal behaviors can be scary for school professionals to deal with. Please reach out at any time for consultation or to discuss the enhancement of your onsite MTSS or other mental health services.