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December 1, 2017
Vol. 75
No. 4

Hurting From the Inside Out: Understanding Self-Injury

It's a paradox: Some students habitually hurt themselves physically to feel better emotionally. When educators understand more, they can help more.

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School CultureSocial-emotional learning
Maria is a counselor in a school where there's been a recent uptake in self-injury among students. Recently, a student's mother contacted Maria about her daughter, Rachel, who had started cutting herself early in 6th grade. Rachel's mother had thought Rachel was going through a phase, but as the year progressed, Rachel continued to self-injure.
Non-suicidal self-injury (often referred to as NSSI), the deliberate destruction of body tissue without suicidal intent and for purposes not socially sanctioned (Nock, 2009), is perplexing for many school staff. They wonder why someone would deliberately hurt him- or herself and whether a young person who does so is suicidal. Mostly, they wonder how to help a student who engages in self-injury. Such behavior seems at odds with the basic human instinct of survival. Hearing students say they self-injure to feel better is even more confusing. Self-injury's visceral association with suicide and the unusual challenges it poses to staff (and other students) make it a critical mental health issue for educators to come to grips with.
Self-injury is common among students, especially adolescents. The example of Rachel, for instance, is based on a real situation that an educator taking a course of Janis's shared. Approximately 18 percent of school-based youth report self-injuring at least once in their lives. Some studies show higher rates (Swannell et al., 2014). More than a third of adolescents know someone else who self-injures (Hasking, Andrews, & Martin, 2013). The average age when a youth starts self-harming is 15, but reports of self-injury among elementary school students are growing (Whitlock & Selekman, 2014; Barrocas et al., 2012). As professionals who've long worked with self-injury and young people who self-injure, we believe that educators can play a crucial role in helping these students.

Hidden or in Plain Sight

Although self-injury is often more visible among girls, some studies find boys and girls equally likely to engage in self-injury. Common forms of such injury are deliberately cutting or deeply scratching the skin. Self-battery and burning the skin are also common, particularly among boys (Swannell et al., 2014).
Most adolescents who hurt themselves report that it's a coping strategy that helps keep intense emotions at bay—at least in the short term (Klonsky, 2007). In most cases, they aren't truly trying to disfigure or punish themselves. There are a variety of reasons—psychological and physiological—that self-injury "works." Mainly, adolescents report that the physical injury helps distract them from what seems to be an endless cycle of negative thoughts and emotions. The act of harming the body can also help young people feel "something" when they feel numb or disconnected.
The stigma associated with these behaviors leads many young people to hide them, meaning it can be hard to tell if a student is injuring him- or herself (Hasking et al., 2015). In other cases, a student may openly display wounds or share details of their habit with friends. This heightens the risk of self-injury among other students through "social contagion"—the tendency of people in close proximity to a self-injurer (even through social media) to adopt that person's behaviors (Jarvi et al., 2013). For instance, we know of one 9th grader, a popular school football star, who self-injured to cope with the pressure of living up to the high standards he constantly set for himself. He made little effort to hide his wounds and sometimes boasted to friends about his scars and how he got them. The friends of a teen like this who many peers look up to are at risk of imitating his coping strategy.
Each form of self-injury, hidden or more public, poses unique challenges. Given the high rate of this behavior in adolescents, schools are an ideal environment for early detection and intervention, and school leaders have a vital role to play in responding to this mental health problem. Let's look at practical ways schools and teachers can help young people who self-injure, including how to talk safely about this problem.

Protocols and Point People

Although mental health professionals like school psychologists are often at the front lines of students' well-being when self-injury is an issue, a whole-school approach is crucial (Whitlock & Rodham, 2013). We recommend that schools have a clear policy and protocol in place for addressing non-suicidal self-injury (Hasking et al., 2016). This protocol should be different from the school's suicide protocol; however, because all students who engage in self-injury are at heightened risk for suicidal thoughts and behaviors, they should be assessed for suicidal tendencies as well.
A comprehensive self-injury protocol should specify the roles each staff member—teachers, school leaders, and school counselors—will play in assisting students who self-injure. (See "" for links to sample protocols.) It's best to have a point person or a team of trained people who can be the main point of contact for students, and whom teachers can refer a student to if they become aware that a student is self-injuring. This point person or team can conduct an accurate risk assessment, determining what's underlying the behavior and whether it's an indicator of more severe psychological concerns.
Like other mental health challenges students face, self-injury can cause discomfort among staff members. It's helpful for staff to agree on who is best prepared to assist students so that if a student discloses his or her self-injuring to a teacher, he or she can connect that youth directly to the most capable staff member. Every staff member need not be comfortable with the kinds of emotions or behaviors behind self-injury—but they should know who on the staff is.
In most cases, this person will be a school mental health professional who is connected to external services and can refer students to outside supports. For instance, in the opening example, Maria was the counselor in her school designated to help when self-injury surfaced.

Learning the Signs, Reaching Out

The point person or team can provide training for school staff, ensuring all members of the school community have a basic understanding of self-injury, the coping functions it serves, and how to communicate with students who self-injure (Hasking et al., 2016). Enhancing school staff members' capacity to notice and respond to broad signs of any mental health challenge will increase the likelihood they will notice self-injury. Signs of self-harm to look for include:
▪ Fresh wounds, often clustered in one area of the body in some patterned way (such as a series of small horizontal or vertical lines or a symbol). Wrists, hands, thighs, ankles, shoulders, and the belly are common places for self-injury.
▪ Clustered and patterned scars.
▪ Constant use of wristbands to cover scars on wrists and arms.
▪ Unseasonal dress; wearing long sleeves or jeans, even when the weather is hot, or refusing to engage in activities that require less coverage (like swimming).
Note that changes in mood—like depression, anxiety, or big ups and downs—often accompany these signs.
Shock, fear, and even disgust are common when someone discovers a person is hurting themselves physically. But how we interact with self-harming students is critically important in fostering help seeking and offering support, so educators must guard against showing negative reactions. A student who perceives that the adults in his or her life are being judgmental, dismissive, or otherwise invalidating is unlikely to confide in adults in the future—and likely to resist seeking additional support, even if the behavior becomes more severe (Berger, Hasking & Martin, 2013).
Students often hesitate to talk to someone at school about their own or a friend's self-injury because they're afraid they're going to get in trouble. They might fear that their parents will be notified, that they'll be taken out of school, that their self-injuring friend might find out who said something and be angry with them, or simply that adults they respect will feel disappointed in them (Berger et al., 2013).
There are no scripts for responding to concerns like these. But we have learned that it helps a student in distress feel supported when school staff respond with respect, validation of core student concerns, and curiosity, when warranted. It's not necessary to talk about the specific wounds, especially for staff members who aren't medical or mental health professionals. What's essential is seeking to understand the student's perception of how self-harming helps and what makes the situation worse and better.
Consider how Maria spoke with Rachel as their relationship progressed. She asked Rachel to come see her during one of her study periods. After asking about how she was doing and how her classes were going, Maria told Rachel that she had become aware of Rachel's cutting through someone who cared for Rachel and was worried about her.
Rather than ask a lot of questions, Maria told Rachel that she understood self-injury sometimes helps people feel better when they're feeling overwhelmed or detached from life. She didn't push Rachel to share a lot of details, but she could tell from Rachel's demeanor and nods that she was on track. Maria asked if Rachel had any questions about stress and self-injury and told her that she could help Rachel understand more about it. Maria talked about the benefits of seeing a counselor outside of school, stressing that a counselor wouldn't tell her mom anything Rachel didn't agree to, and that a therapist's job is to listen without judgment.
Students sometimes struggle to talk about their self-injury. That's OK. Avoid forcing a student to talk about it if he or she isn't ready. Instead, focus on communicating that you want to help, that supports are out there, and that you can connect the student with someone you trust who is in a position to help (Whitlock & Rodham, 2013).
It's preferable to bring in parents when supporting a youth who self-injures. Family support is a significant predictor of whether a young person ceases their self-injury (Whitlock, Prussein, & Pietrusza, 2015). However, the family environment might be contributing to the reasons a young person is self-injuring, so school staff should carefully consider the student's home environment when determining how best to involve parents.

Schoolwide Strategies

Address the issue of self-harm openly through assemblies or awareness-raising campaigns. Let everyone know they can come to a school adult about this reality without facing judgment. Communicate to students that people respond to stress in different ways, and that getting help from an adult is something to take pride in; this addresses the stigma associated with seeking help. Validate students' fears that they might get in trouble, but emphasize that the benefits of getting help (for oneself or a friend) outweigh the risks. Doing so will help students open up about their experiences.
Make sure students know that the school is interested in helping—not punishing—and will work with students to address their fears in ways everyone feels good about. Of course, this only works if all school staff adopt an empathic, supportive demeanor when talking to students who self-injure.
It is important, particularly for school counselors and other mental health staff, to understand that recovery from self-injury is a process—and isn't always smooth sailing. Young people can express ambivalence about their self-injury; they want to stop, but also feel the need to hold on to their habit as a coping strategy. Even young people who haven't self-injured for years have told us they still sometimes feel the urge to do so.

Avoiding "Contagion"

Concerns that discussing self-injury may inadvertently encourage it are common. Because contagion can and does occur, it's wise to be thoughtful about how you approach the reality of self-injury with individual students and the student body as a whole. Rather than providing in-depth information about practices like cutting, we encourage staff to focus on helping students recognize underlying motives and triggers in themselves—or in friends and peers. Similarly, helping students know how best to support a peer's struggle and what trusted adult they can turn to increases the likelihood that struggling students will receive help when they need it (Whitlock & Rodham, 2013).
Where a student has been clearly identified as a source of contagion for others, it's important to help that student understand the effects that talking about the ritual and showing wounds or scars might have on others. It's always useful to engage students—even those who are influencing others in a harmful way—as allies in a school's mission to care for students. Some students will respond positively to being regarded as important; they may not only comply with staff requests, but also have good ideas for how to intervene and support vulnerable students (Hasking et al., 2016).
Through our work with educators, we heard of a counselor who made an ally of a teen ("Joey") who was contributing to self-injury activity among a group of 9th grade friends by openly discussing and displaying his cuts. The counselor invited Joey to go for a walk. He shared his concerns with the boy and worked to help him see how his behavior, coupled with his high status within his peer group, was creating a situation that could harm one or more of his friends. He asked Joey to help ensure that his peers didn't end up hurting themselves more than they intended—but didn't demand that Joey decide right away. Eventually, Joey agreed not to talk about self-injury or show his cuts to his peers. He told his friends that he didn't think it was a good idea to cut—and that he was working on stopping.
When students cannot be productively engaged, calmly communicate non-negotiable requirements, such as not displaying self-inflicted wounds freely. Schools should also do everything they can to ensure that youth who chronically self-injure have access to therapy.

Heightened Suicide Risk

Non-suicidal self-injury, by definition, isn't a suicidal act. Although behaviors discussed here are associated with anxiety and depression, most people who self-injure say that doing so helps them feel better when they're anxious, stressed, or depressed. It's important to note, however, that people who self-injure are at increased risk of concurrent or subsequent suicidal thoughts and behaviors (Whitlock et al., 2013) because self-injury and suicidal thoughts or behaviors share common risk factors and because the very act of engaging in self-injury can make it easier to hurt oneself if a person becomes actively suicidal.
Because self-injuring can signal heightened suicide risk, schools must craft thoughtful protocols for responding to a self-harming youth. For instance, after Maria had established rapport with Rachel, she asked her if she ever felt suicidal. Rachel said no—she just cut herself to feel better. If she'd said yes, Maria would've explored Rachel's feelings or actions further. Maria also asked Rachel how she takes care of her wounds and ensured that Rachel knew it was important to get help from someone if she ever cut deeper than she intended.

Breakthroughs for Rachel

When we last checked in with Rachel, she'd been meeting regularly with Maria for three months and was also seeing an outside counselor, who had reached out to Maria to learn more about Rachel. Rachel is getting help because her school had a process in place. When schools and school adults respond to self-injury in an empathetic, responsible manner that empowers both staff and students, more youth like Rachel will get the help they need.
Author's Note: All names of students and counselors are pseudonyms.

Resources on Students and Self-Injury

These resources can help your school learn about self-injury and how to assist students and families.

<BQ> ▪ Non-suicidal self-injury in schools: Developing and implementing a school protocol by Kate Bubrick, Jaclyn Goodman, and Janis Whitlock. Cornell, NY: Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults. Available at www.selfinjury.bctr.cornell.edu/documents/schools.pdf (Under Resources tab).

Seeking solutions to self-injury: A guide for school staff by University of Queensland, Brisbane, Australia. Available at www.familyconcernpublishing.com.au/product/seeking-solutions-to-self-injury-the-school-staff-guide-2nd-edition

Seeking solutions to self-injury: A guide for young people by University of Queensland, Brisbane, Australia. Available at www.familyconcernpublishing.com.au/product/seeking-solutions-to-self-injury-the-young-peoples-guide/

Knowledge and experiences of school staff towards student self-injury: Final report for schools and universities by Emily Berger, Penelope Hasking, and Andrea Reupert. Australia: Monash University. Available at www.self-injury.org.au (Under Resources/For schools and parents tabs).

Seeking solutions to self-injury, 2nd edition by G. Martin, P. Hasking, S. Swannell, M. Lee, M. McAllister, & K. Greisbach. Brisbane: Australia: Centre for Suicide Prevention Studies at the University of Queensland. Available at https://spawa.wikispaces.com/file/view/DSH+school+staff+UQ+2011.pdf 

Online Trainings

▪ Cornell Research Program for Self-Injury and Recovery Training (Non-Suicidal Self-Injury 101) Available at www.selfinjury.bctr.cornell.edu/training.html ($40.00, discounts available)

▪ Signs of Self-injury Prevention Program. Available from Screening for Mental Health, Inc. at www.mentalhealthscreening.org/products/signs-of-self-injury-/youth-prevention-programs-1 ($225.00)

Websites

▪ Self-injury Recovery & Resources: www.selfinjury.bctr.cornell.edu

▪ Self-injury Outreach and Support: http://sioutreach.org </BQ>

References

Barrocas, A. L., Hankin, B. L., Young, J. F., & Abela, J. R. (2012). Rates of nonsuicidal self-injury in youth: Age, sex, and behavioral methods in a community sample. Pediatrics, 130(1), 39–45.

Berger, E., Hasking, P., & Martin, G. (2013). "Listen to them": Adolescents views on helping young people who self-injure. Journal of Adolescence, 36, 935–945.

Hasking, P., Andrews, T., & Martin, G. (2013). The role of exposure to self-injury among peers in predicting later self-injury. Journal of Youth and Adolescence, 42(10), 1543–1546.

Hasking, P. A., Heath, N. L., Kaess, M., Lewis, S. P., Plener, P. L., Walsh, B. W., Whitlock, J., & Wilson, M. S. (2016). Position paper for guiding response to non-suicidal self-injury in schools. School Psychology International, 37(6), 644–663.

Hasking, P., Rees, C. S., Martin, G., & Quigley, J. (2015). What happens when you tell someone you self-injure? The effects of disclosing NSSI to adults and peers. BMC Public Health, 15, 1039.

Jarvi, S., Jackson, B., Swenson, L., & Crawford, H. (2013). The impact of social contagion on non-suicidal self-injury: A review of the literature. Archives of Suicide Research, 17, 1–19.

Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226–239.

Nock, M. K. (2009). Why do people hurt themselves? New insights into the nature and functions of self-injury. Current Directions in Psychological Science, 18, 78–83.

Swannell, S. V., Martin, G. E., Page, A., Hasking, P., & St. John, N. (2014). Prevalence of non-suicidal self-injury in nonclinical samples: Systematic review, meta-analysis and meta-regression. Suicide & Life-Threatening Behavior, 44, 273–303.

Whitlock, J., Muehlenkamp, J., Eckenrode, J., Purington, A., Barrera, P., Baral-Abrams, G., et al. (2013). Non-suicidal self-injury as a gateway to suicide in adolescents and young adults. Journal of Adolescent Health, 52(4), 486–492.

Whitlock, J. L., Prussein, K., & Pietrusza, C. (2015). Predictors of non-suicidal self-injury and psychological growth. Child and Adolescent Psychiatry and Mental Health, 9(19).

Whitlock, J., & Rodham, K. (2013). Understanding NSSI in youth. School Psychology Forum: Research in Practice, 7(4), 93–110.

Whitlock, J. L., & Selekman, M. (2014). Non-suicidal self-injury (NSSI) across the lifespan. In Oxford Handbook of Suicide and Self-Injury. M. Nock (Ed.) Oxford, U.K.: Oxford University Press.

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