Self-injury & Recovery Resources (SIRR)

About self-injury

What is self-injury?
Who self-injures?
How common is self-injury among adolescents and young adults?
When does self-injury start and how long does it last?
Why do people self-injure?
Is self-injury a suicidal act?
What factors contribute to self-injurious behavior?
Is self-injury addictive?
Is self-injury contagious?
What are the dangers of self-injury?
Are rates of self-injurious behavior increasing in the adolescent and young adult population?
Detection, intervention, & treatment
Prevention
References


  • What is self-injury?

    Nonsuicidal self-injury (NSSI) is the deliberate, self-inflicted destruction of body tissue resulting in immediate damage, without suicidal intent and for purposes not culturally sanctioned.

    Self-injury can include a variety of behaviors but is most commonly associated with:

    ◦ intentional carving or cutting of the skin
    ◦ subdermal tissue scratching
    ◦ burning oneself
    ◦ banging or punching objects or oneself with the intention of hurting oneself
    ◦ embedding objects under the skin

    Tattoos and body piercing are not typically considered self-injurious unless undertaken with the intention to harm the body.

    Although cutting is one of the most common and well documented forms, there are many things people do to hurt themselves. In fact, our studies have documented over 16 forms of self-injury and there may well be more. Moreover, it is clear that number of forms used by an individual varies significantly; from 1 to over 10. Self-injury can be and is performed on any part of the body, but most often occurs on the hands, wrists, stomach and thighs. The severity of the act can vary from superficial wounds to those resulting in lasting disfigurement. Indeed, about 33% of people who reported self-injury in two college studies said that they had hurt themselves so badly that they should have been seen by a medical professional; only 6.5% had ever been treated for any of their wounds.

    What defines self-injury has less to do with what it looks like (e.g. in what particular way someone hurts his/her body) than with the intention one has when doing it. Because NSSI can look so much like a suicidal gesture, it can be confusing, and often frightening, to those who see it but who do not know what it means. This is one of the reasons that it is important to assess the why of the injuries as well as the what.

    Click here to read about our online training course NSSI 101.

    Check out our infographic covering the basics of self-injury here.

    For downloadable CRPSIR resources click here.

    Select Sources:

    International Society for the Study of Self-injury. (2018, May). What is self-injury? Retrieved from: https://itriples.org/about-self-injury/what-is-self-injury.

    Laye-Gindhu, A. & Schonert-Reichl, K. A. (2005). Nonsuicidal self-harm among community adolescents: Understanding the “whats” and “whys” of self-harm. Journal of Youth and Adolescence, 34, 447-457.

    Whitlock, J, Muehlenkamp, J., Purington, A., Eckenrode, J., Barreira, J., Abrams, G.B., Marchell, T., Kress, K., Girard, K., Chin, C., Knox, K. (2011). Non-Suicidal Self-Injury in a College Population: General Trends and Sex Differences. Journal of American College Health, 59(8): 691-698.

  • Who self-injures?

    When it comes to self-injury, there is no one “profile.” Although media tends to represent self-injury as a largely female, middle to upper middle-class, white phenomenon, studies simply do not support this. In fact, there is no evidence for differences in self-injury by socioeconomic status and very little research supports differences by race or ethnicity.

    It is commonly assumed that girls/women are significantly more likely to self-injure than guys/men. In truth, however, this gender divide is not always supported. Studies either tend to find that females and males self-injure at the same rates or that females are a little more likely to injure than males, but not a lot. What does seem to vary by gender is age of onset, length of time self-injuring and methods of injuring. In general, studies find that females are more likely to start younger and to injure longer, using forms, like cutting, that can be more serious than some of the forms males use, like punching. Males are more likely than females to report a social component (e.g., injuring in the presence of others or letting others injure them), and to report injuring while drunk or high. Studies of NSSI in transgender or agendered individuals are rare since it can be so difficult to gather enough data to make inferences in these populations.

    Of all of the demographic characteristics studied, the only thing that consistently shows up as a potent predictor of self-injury is sexual orientation. Studies consistently find that reporting oneself as bisexual (or being sexually attracted to males and females equally) is a really strong risk factor for self-injury, especially among females. Being lesbian or gay does not seem to carry much elevated risk above and beyond being straight. Why we see such a strong association for bisexual females and self-injury is unclear, but has begun to be investigated by researchers in the self-injury field with hopes that we might understand and intervene in supportive ways.

    Select Sources:

    Andover, M. S., Primack, J. M., Gibb, B. E., & Pepper, C. M. (2010). An examination of non-suicidal self-injury in men: Do men differ from women in basic NSSI characteristics? Archives of Suicide Research: Official Journal of the International Academy for Suicide Research, 14, 79–88.

    Baetens, I., Claes, L., Onghena, P., Muehlenkamp, J., & Grietens, H. (2011). Non-suicidal and suicidal self-injurious behavior among Flemish adolescents: A web-survey. Archives of Suicide Research, 15(1), 56-67

    Andrews, T., Martin, G., Hasking, P., & Page, A. (July 01, 2013). Predictors of Continuation and Cessation of Nonsuicidal Self-Injury. Journal of Adolescent Health, 53, 1, 40-46.

    Whitlock, J, Muehlenkamp, J., Purington, A., Eckenrode, J., Barreira, J., Abrams, G.B., Marchell, T., Kress, K., Girard, K., Chin, C., Knox, K. (2011). Non-Suicidal Self-Injury in a College Population: General Trends and Sex Differences. Journal of American College Health, 59(8): 691-698.

    Marshall, E., Claes, L., Bouman, W. P., Witcomb, G. L., & Arcelus, J. (2016). Non-suicidal self-injury and suicidality in trans people: a systematic review of the literature. International review of psychiatry, 28(1), 58-69.

    Gholamrezaei, M., De Stefano, J., & Heath, N. L. (2017). Nonsuicidal self‐injury across cultures and ethnic and racial minorities: A review. International journal of psychology, 52(4), 316-326.

    For downloadable CRPSIR resources click here

  • How common is self-injury among adolescents and young adults?

    Because it so often occurs in private, it is very difficult to identify one or more discrete self-injurer “profiles.” Unless being treated for related conditions, such as depression or anxiety, detecting self-injurious individuals can be very difficult. This made initial studies of self-injury prevalence difficult. However, over the past half decade or so, an increasingly large and diverse set of studies have given us a reasonably good picture of self-injury prevalence. In a recent meta analysis (a study of other studies) of all prevalence studies conducted to date worldwide, the pooled estimate for adolescents was 17.2% among adolescents, 13.4% among young adults, and 5.5% among adults. Rates vary, however, depending on time, place and location. In general, US studies tend to find that lifetime prevalence of common self-injury ranges from 12% to 37.2% in secondary school populations and 12% to 20% in young adult populations.

    Select Sources:

    Swannell, S.V., Martin, G.E., Page, A., Hasking, P., & St. John, N.J. (2014). Prevalence of nonsuicidal self-injury in nonclinical samples: Systematic review, meta-analysis and meta-regression. Suicide and Life-Threatening Behavior, 2, 1-31.

    For downloadable CRPSIR resources click here

  • When does self-injury start and how long does it last?

    Self-injury scholarship consistently shows an average age of onset between 11-15 years with a normally distributed age of onset ranging from about 10–24. Of all youth reporting any self-injury, over three quarters report repeat more than 1 episode and an estimated 6%-7% of adolescents report self-injury in the past year. Overall, about a quarter of all adolescents and young adults with self-injury history report practicing it only once in their lives, but since even a single self-injury episode is significantly correlated with a history of abuse and conditions such as suicidality and psychiatric distress there may be a group of adolescents in which a single incident of self-injury serves as a risk indicator for other risk behaviors or mental health challenges. Duration of self-injury is understudied but available evidence suggests that among individuals with a history of repeat self-injury but who are otherwise doing alright in life, the majority stop within 5 years of starting. For many self-injury is cyclical rather than linear meaning that it is used for periods of time, stopped, and then resumed.

    Select Sources:

    Whitlock, J.L. & Selekman, M. (2014). Non-suicidal self-injury (NSSI) across the lifespan. In M. Nock (Ed.), Oxford handbook of suicide and self-injury. Oxford Library of Psychology, Oxford University Press.

    Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal self-injury: a systematic review. Frontiers in psychology, 8, 1946.

    For downloadable CRPSIR resources click here

  • Why do people self-injure?

    Reasons given for self-injuring are diverse. Many individuals who practice it report overwhelming sadness, anxiety, or emotional numbness as common emotional triggers. Self-injury, they report, provides a way to manage intolerable feelings or a way to experience some sense of feeling. It is also used as means of coping with anxiety or other negative feelings and to relieve stress or pressure. Those who self-injure also report doing so to feel in control of their bodies and minds, to express feelings, to distract themselves from other problems, to communicate needs, to create visible and noticeable wounds, to purify themselves, to reenact a trauma in an attempt to resolve it or to protect others from their emotional pain. Some report doing it simply because it feels good or provides an energy rush (although few report doing only for these reasons). Regardless of the specific reason provided, self-injury may best be understood as a maladaptive coping mechanism, but one that works – at least for a while.

    Select Sources:

    Klonsky, E.D. & Glenn, C.R. (2009). Assessing the functions of non-suicidal self-injury: Psychometric properties of the Inventory of Statements About Self-injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31, 215-219.

    Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72, 885-890.

    Taylor, P. J., Jomar, K., Dhingra, K., Forrester, R., Shahmalak, U., & Dickson, J. M. (2018). A meta-analysis of the prevalence of different functions of non-suicidal self-injury. Journal of Affective Disorders, 227, 759-769.

    Watch a short video about why individuals may engage in self-injury:

    Why Self-Injure? from Cornell Self Injury & Recovery on Vimeo.

  • Is self-injury a suicidal act?

    There are important distinctions between those attempting suicide and those who practice self-injury behaviors in order to cope with overwhelming negative feelings or no feeling at all (dissociation). Perhaps one of the most paradoxical features of self-injury is that most of those who practice self-injury report doing so as a means of relieving pain or of feeling something in the presence of nothing. Indeed, studies find that most people with non-suicidal self-injury history report not considering suicide at all. Nevertheless, the particular relationship between self-injury undertaken without suicidal intent and self-injury undertaken with suicidal intent are not clear since individuals who report the former are also more likely to report having considered or attempted suicide.

    Studies of what predicts likelihood of moving from non-suicidal self-injury (NSSI) to suicide thoughts and behaviors (including attempt) find that risk increases as lifetime incidence of NSSI increases (interestingly, this risk plateaus and decreases after about 50 lifetime incidents) and as sense of hopelessness increases. Among adolescents and young adults, risk of suicide thoughts and behaviors increases as positive connection to parents decreases (presence of positive connection to parents is also a strong protective factor). It is really important to note that while non-suicidal self injury does not cause or lead to suicide thoughts and / or behaviors, it does lower inhibition to suicide behaviors if one begins to feel suicidal since people who have practice hurting their bodies may find it easier to hurt themselves lethally.

    Select Sources:

    Hamza, C.A., Stewart, S.L. & Willoughby, T. (2012). Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model. Clinical Psychology Review, 32, 482-495.

    Whitlock, J., Muehlenkamp, J., Eckenrode, J., Purington, A., Barrera, P., Baral-Abrams, G., Kress, V., Grace Martin, K, Smith, E., (2013). Non-suicidal self-injury as a gateway to suicide in adolescents and young adults. Journal of Adolescent Health, 52(4): 486-492.

    Matney, J., Westers, N. J., Horton, S. E., King, J. D., Eaddy, M., Emslie, G. J., … & Stewart, S. M. (2018). Frequency and methods of nonsuicidal self-injury in relation to acquired capability for suicide among adolescents._ Archives of suicide research_, 22(1), 91-105.

    Mbroh, H., Zullo, L., Westers, N., Stone, L., King, J., Kennard, B., … & Stewart, S. (2018). Double trouble: Nonsuicidal self-injury and its relationship to suicidal ideation and number of past suicide attempts in clinical adolescents. Journal of affective disorders, 238, 579-585.

    May, A. M., & Victor, S. E. (2018). From ideation to action: recent advances in understanding suicide capability. Current opinion in psychology, 22, 1-6.

    Olfson, M., Wall, M., Wang, S., Crystal, S., Bridge, J. A., Liu, S. M., & Blanco, C. (2018). Suicide after deliberate self-harm in adolescents and young adults. Pediatrics, 141(4), e20173517.

    For downloadable CRPSIR resources click here

  • What factors contribute to self-injurious behavior?

    In clinical populations, self-injury is strongly linked to childhood abuse, especially childhood sexual abuse. In addition, there is evidence that earlier, more severe abuse and abuse by a family member may lead to greater dissociation and thus greater self-injury. Self-injury is also linked to eating disorders, substance abuse, post-traumatic stress disorder, borderline personality disorder, depression, and anxiety disorders. The lack of empirical research in non-clinical populations reinforces the assumption that most or all of SIB is a product of pre-existing disorders, although more recent research in general populations of adolescent and young adults challenges this assumption..

    For downloadable CRPSIR resources click here

    Select sources:

    Brodsky, B. S., Cloitre, M., & Dulit, R. A. (1995). Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder. The American journal of psychiatry, 152(12), 1788.

    Van der Kolk, B. A., Perry, J. C., & Herman, J. L. (1991). Childhood origins of self-destructive behavior. American journal of Psychiatry, 148(12), 1665-1671.

    Yates , T. M. (2004). The developmental psychopathology of self-injurious behavior: Compensatory regulation in posttraumatic adaptation. Clinical Psychology Review, 24(1), 35-78.

    Kokaliari, E. D. (2005). Deliberate self-injury: An investigation of the prevalence and psychosocial meanings in a non-clinical female college population (Doctoral dissertation, ProQuest Information & Learning).

    Whitlock, J. L., Powers, J. L., & Eckenrode, J. (2006). The virtual cutting edge: the internet and adolescent self-injury. Developmental psychology, 42(3), 407.

    Valencia-Agudo, F., Burcher, G. C., Ezpeleta, L., & Kramer, T. (2018). Nonsuicidal self-injury in community adolescents: A systematic review of prospective predictors, mediators and moderators. Journal of Adolescence, 65, 25-38.

    Abdelraheem, M., McAloon, J., & Shand, F. (2018). Mediating and moderating variables in the prediction of self-harm in young people: A systematic review of prospective longitudinal studies. Journal of affective disorders.

  • Is self-injury addictive?

    Most self-injury researchers agree that self-injury does show some addictive qualities and may serve as a form of self-medication for some individuals. In our studies with college students, about a third of those who report using self-injury regularly report having a difficult time controlling their urge to self-injure. Moreover, interviews conducted for several of the studies associated with this project shows that many people who self-injure describe both the immediate effect and overall practice as something with addictive properties. The immediate effects of pain release mood-boosting endorphins, while the delayed effects are damaging, reinforcing addictive maladaptive coping strategies that induces shame. For example, many interviewees talk about moments of feeling the strong need to injure even when there is no obvious trigger and about having “self-injury free” hours or days. They also liken it to other drugs and talk about needing increasingly more or deeper injuries to feel the same effect. Recognition of the addictive properties of self-injury for some individuals is the basis for the “addiction hypothesis.” The addiction theory suggest that self-injurious acts may solicit involvement of the endogenous opioid system (EOS) which regulates both pain perception and levels of endogenous endorphins which occur as a result of injury. The activation of this system can lead to an increased sense of comfort or integration, at least for a short period of time. Repeated activation of the EOS can cause a tolerance effect: Over time those who self-injure may feel less pain while injuring. Overestimation of the EOS can then lead to actual withdrawal symptoms which in turn lead to more self-injurious behavior. Some support for the addiction hypothesis has been found in recent studies of whether addiction models apply to self-injury.

    For downloadable CRPSIR resources click here

    Select sources:

    Grossman, R., & Siever, L. (2001). Impulsive self-injurious behaviors. Self-injurious behaviors: Assessment and treatment, 117.
    Walsh, B. W. (2005). Treating self injury: A practical guide. New York: Guilford Press.

    Favazza, A.R. and Rosenthal,R.J. (1993) Diagnostic Issues in Self-Mutilation. Psychiatric Services, 44(2):134-140. http://ps.psychiatryonline.org/doi/abs/10.1176/ps.44.2.134

    Nixon, M.K., Cloutier, P.F., and Aggarwal, S. (2002). Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. J Am Acad Child Psychiatry, 41(11):1333-41. https://www.ncbi.nlm.nih.gov/pubmed/12410076

    Blasco-Fontecilla, H., Fernández-Fernández, R., Colino, L., Fajardo, L., Perteguer-Barrio, R., & de Leon, J. (2016). The Addictive Model of Self-Harming (Non-suicidal and Suicidal) Behavior. Frontiers in Psychiatry, 7:8. http://doi.org/10.3389/fpsyt.2016.00008

    Hicks, K.M., and Hink, S.M. (2008) Concept analysis of self mutilation. J Adv Nurs, 64(4):408-13. https://www.ncbi.nlm.nih.gov/pubmed?Db=pubmed&Cmd=ShowDetailView&TermToSearch=19006819

  • Is self-injury contagious?

    The seemingly rapid spread of self-injury behavior among community populations of youth suggests that there may be a contagion factor at work. Key early studies show patterns of social contagion even before the internet and social media (Walsh & Rosen, 1985). Indeed, self-injurious behavior has been shown repeatedly to follow epidemic-like patterns in institutional settings such as hospitals and detention facilities. Lynch and Cozza (2009) suggest that discussion of specific acts of NSSI among individuals who self-injure has been shown to attenuate social contagion in group treatment settings. For many, however self-injury is a very private, hidden act. Multiple studies show that for many who self-injure, no one knows or suspects that they injure. However, anecdotal reports from adults working with youth in school settings report a fad quality to the behavior, similar to that which occurs with eating disorders. Consistent with this, survey results of secondary school nurses, counselors and social workers suggest that there may be multiple forms of self-injury in middle and high school settings – some of which include groups of youth injuring together or separately as part of a group membership. Exposure to peer NSSI may put adolescents with comorbid psychiatric conditions at a particularly high risk of perceiving NSSI as a favorable coping strategy.Causes for the spread of the behavior in nonclinical populations have left many wondering what larger contextual factors might be at work. Recent research suggests that the Internet and the increasing prevalence of self-injury in popular media, such as movies, books, and news reports may play a role in the spread of self-injury.

    For downloadable CRPSIR resources click here

    Select sources:

    Taiminen, T. J., Kallio-Soukainen, K., Nokso-Koivisto, H., Kaljonen, A., & Helenius, H. (1998). Contagion of deliberate self-harm among adolescent inpatients. Journal of the American Academy of Child & Adolescent Psychiatry, 37(2), 211-217.

    Rosen, P. M., & Walsh, B. W. (1989). Patterns of contagion in self-mutilation epidemics. The American Journal of Psychiatry, 146(5), 656.

    Walsh, B. W. ( 2005). Treating self-injury: A practical guide. New York: Guilford Press.

    Purington, A., & Whitlock, J. (2010). Non-suicidal self-injury in the media. The Prevention Researcher, 17(1), 11-14.

    Whitlock, J., Purington, A., & Gershkovich, M. (2009). Media, the Internet, and nonsuicidal self-injury. In M. K. Nock (Ed.), Understanding nonsuicidal self-injury: Origins, assessment, and treatment (pp. 139-155). Washington, DC, US: American Psychological Association.

    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), 1–19. http://doi.org/10.1080/13811118.2013.748404

    Quigley, J., Rasmussen, S., & McAlaney, J. (2017). The associations between children’s and adolescents’ suicidal and self-harming behaviors, and related behaviors within their social networks: A systematic review. Archives of suicide research, 21(2), 185-236.

    Brown, R. C., Fischer, T., Goldwich, A. D., Keller, F., Young, R., & Plener, P. L. (2018). # cutting: Non-suicidal self-injury (NSSI) on Instagram. Psychological medicine, 48(2), 337-346

    Hong, V., Ewell Foster, C. J., Magness, C. S., McGuire, T. C., Smith, P. K., & King, C. A. (2018). 13 Reasons Why: viewing patterns and perceived impact among youths at risk of suicide. Psychiatric services, 70(2), 107-114.

  • What are the dangers of self-injury?

    Why worry about self-injury? This is a common question, particularly among people who see it as an attention seeking behavior or as something that will pass in time. It is important to know that self-injury is often a sign of other more serious conditions. This is particularly true when it is regularly used or when the types of self-injury used could cause severe or lethal damage, as is the case with cutting, one of the most common forms of self-injury. Non-suicidal self-injury is, by definition, a behavior that does not include suicidal intent. Instead, it most often is used to preserve and enhance life, to return to a state of equilibrium and balance or emotional integration when one feels extremely out of sorts. That said, self-injury is a potent risk factor for current or later suicidal thoughts and behaviors. And, while self-injury does not cause it or lead to suicidal thoughts and/or behaviors, the fact that one has practiced hurting one’s body may make it easier to make a suicide attempt if the distress becomes acute enough. The fact that someone uses it at all suggests that they are experiencing high levels of psychological distress, even if not all the time. Studies also show that relatively few individuals who self-injure seek medical assistance when they severely injure themselves. Because of the potential link between self-injury and suicide, self-injury should always be taken seriously, particularly if a person is injuring regularly or using methods that can cause a lot of damage to the body (like cutting).

    In addition to being linked to suicide, self-injury is often a sign that other worrisome psychological conditions may be present, such as depression, anxiety, or disordered eating. Moreover, the scars that self-injury leaves on the body can serve as a reminder that cause discomfort and distress of their own, long after the emotional challenges that lead to self-injury are resolved. Having to explain to family members, friends, bosses, peers, and other people why there are marks all over the body has been reported as an ongoing source of stress for many people who no longer self-injure but bear a high degree of scarring. Lastly, self-injury is extremely stressful for those who love and or live with someone who uses it to regulate emotion.

    For downloadable CRPSIR resources click here

    Select sources:

    Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious behaviors in a college population. Pediatrics, 117(6), 1939-1948.

    Haw, C., Casey, D., Holmes, J. and Hawton, K. (2015), Suicidal Intent and Method of Self-Harm: A Large-scale Study of Self-Harm Patients Presenting to a General Hospital. Suicide Life Threat Behav, 45: 732–746. doi: 10.1111/sltb.12168

    Whitlock,J. Muehlenkamp, J. and Eckenrode, J. (2008). Variation in Nonsuicidal Self-Injury: Identification and Features of Latent Classes in a College Population of Emerging Adults. Journal of Clinical Child & Adolescent Psychology, 37(4), 725-735. doi: 10.1080/15374410802359734

    Whitlock, J., Muehlenkamp,J., Eckenrode, J., Purington, A., Abrams, G.B., Barreira, P., and Kress, V. (2012). Nonsuicidal Self-Injury as a Gateway to Suicide in Young Adults. Journal of Adolescent Health, 52, 486-492. http://dx.doi.org/10.1016/j.jadohealth.2012.09.010

    Rothenberg, P. and Whitlock, J. (2013). Wounds heal but scars remain: Responding when someone notices and asks about your past self-injury. The Practical Matters Series, Cornell Research Program on Self-Injury and Recovery. Cornell University. Ithaca, NY http://www.selfinjury.bctr.cornell.edu/perch/resources/wounds-heal-pm-2.pdf

  • Are rates of self-injurious behavior increasing in the adolescent and young adult population?

    This is impossible to know because we have no idea precisely how common self-injury used to be in community populations of adolescents and young adults. In assessing changes in NSSI rates it is important to consider that sample selection and NSSI categorization and measurement could impact prevalence and incidence rates. There is broad consensus, however, among researchers and those who work directly with young people that the phenomenon has increased over time, particularly since about 2000. Studies of changes in the number of adolescents who present for self-injurious treatment in hospitals has shown an increase and the presence of self-injury in new and popular forms of media, such as in newspapers, increased dramatically from the 1990s to today. Whether the increasing attention to self-injury is due to the fact that more youth are actually engaging in the behavior, to increased likelihood to seek help, or to an increasing ability among service providers to correctly identify and report the behavior is unclear. It may very well be a combination of all three.

    For downloadable CRPSIR resources click here

    Select sources:

    Whitlock, J.L., Purington, A., Gershkovich, M. (2009). Influence of the media on self injurious behavior. In M. K. Nock (Ed.), Understanding nonsuicidal self-injury: Origins, assessment, and treatment (pp. 139-156). Washington, DC, US: American Psychological Association.

    Whitlock, J., Eells, G., Cummings, N., & Purington, A. (2007). Self-injurious behavior in college populations: Perceptions and experiences of college mental health providers. Manuscript submitted for publication.

    Heath, N. L., Toste, J. R., Nedecheva, T., & Charlebois, A. (2008). An Examination of Nonsuicidal Self-Injury Among College Students. Journal of Mental Health Counseling, 30(2), 137–156. Retrieved from http://search.proquest.com/docview/198689297?accountid=10267

    Nixon, M. K., and Heath, N. L. (2009). Self-injury in youth. The essential guide to assessment and intervention (pp. 9–27). New York: Routledge.

    Laye-Gindhu A., and Schonert-Reichl K.A. (2004). Nonsuicidal self-harm among community adolescents: understanding the “whats” and “whys” of self-harm. J Youth Adolesc., 34(5):447–457. doi: 10.1007/s10964-005-7262-z

    Muehlenkamp J.J., and Gutierrez P.M. (2004). An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide Life Threat Behav., 34(1):12–23. doi: 10.1521/suli.34.1.12.27769

    Ross S., and Heath N. (2002). A study of the frequency of self-mutilation in a community sample of adolescents. J Youth Adolesc., 31(1):67–77. doi: 10.1023/A:1014089117419

    Zetterqvist M., Lundh L-G, Dahlström Ö., and Svedin, C.G. (2013). Prevalence and function of non-suicidal self-injury (NSSI) in a community sample of adolescents, using suggested DSM-5 criteria for a potential NSSI disorder._ J Abnorm Child Psychol_., 41(5):759–773. doi: 10.1007/s10802-013-9712-5

    Zoroglu SS, Tuzun U, Sar V, et al. (2003). Suicide attempt and self-mutilation among Turkish high school students in relation with abuse, neglect and dissociation._ Psychiatry Clin Neurosci_., 57(1):119–126. doi: 10.1046/j.1440-1819.2003.01088.x

    Lynch, T.R., and Cozza, C. (2009). Behavior therapy for nonsuicidal self-injury. In M. K. Nock (Ed.), Understanding nonsuicidal self-injury: Origins, assessment, and treatment (pp. 221-251). Washington, DC, US: American Psychological Association.

    Wester, K., Trepal, H., & King, K. (2018). Nonsuicidal Self‐Injury: Increased Prevalence in Engagement. Suicide and Life‐Threatening Behavior, 48(6), 690-698.

  • Detection, Intervention, & Treatment

    Detecting and intervening in self-injurious behavior can be difficult since the practice is often secretive and involves body parts which are relatively easy to hide. Although experienced therapists in this area can offer advice based on experience, few studies which actually test detection, intervention and treatment strategies have been conducted. The suggestions which follow are those which evolve naturally from existing literature and from interviews with practitioners with significant experience in self-injurious behavior.

    • Unexplained burns, cuts, scars, or other clusters of similar markings on the skin can be signs of self-injurious behavior.

      Arms, fists, and forearms opposite the dominant hand are common areas for injury. However, evidence of self-injurious acts can and do appear on pretty much every body part possible. Other signs include: inappropriate dress for season (consistently wearing long sleeves or pants in summer), constant use of wrist bands / coverings, unwillingness to participate in events / activities which require less body coverage (such as swimming or gym class), frequent bandages, odd / unexplainable paraphernalia (e.g. razor blades or other implements which could be used to cut or pound), and heightened signs of depression or anxiety. When asked, individuals who self-injure may offer stories which seem implausible or which may explain one, but not all, physical indicators such as “It happened while I was playing with my kitten.” It is important that questions about the marks be non-threatening and emotionally neutral. Evasive responses are common. Not knowing how to broach the subject is often what restrains concerned individuals form probing. However, concern for their well-being is often what many who self-injure most need and persistent but neutral probing may eventually elicit honest responses.

    • Schools, parents, medical practitioners, and other youth serving professionals all have an important role to play in identifying self-injury and in assisting youth in getting help.

      Unfortunately, lack of information on self-injury has hampered the creation of informational materials and/or treatment options. The S.A.F.E. Alternatives program in the Linden Oaks Hospital in Edward, Illinois is the one of the only existing inpatient treatment program specific to self-injury in the nation (see www.selfinjury.com). Moreover, while a small but growing body of evidence exists to assist those helping individual self-injurers, little literature exists to explain and address the environmental factors that contribute to adoption of the practice. For those who encounter self-injurious adolescents, creating a safe environment is critical. This can be difficult with youth who have suffered trauma or abuse. Drawing from a number of studies in this area, researchers maintain that structure, consistency, and predictability are important elements in forming relationships with self-injurious youth. Developing plans which emphasize a) taking responsibility for the behavior, b) reducing the harm inflicted by the behavior, c) identifying and more positively reacting to self-injury triggers and physical cues, d) identifying safe people and places for assistance when needing to reduce the urge to self-injure, and e) avoiding objects which could be used to self-injure (e.g., paper clips, staples, erasers, sharp objects) can help to reduce the harm associated with self-injurious practices and establish trust. This plan should serve to help stabilize the student and to provide structure and support until community-based counseling can begin. Parental detection of youth self-harm is associated with increased likelihood of professional help-seeking (Mojtabai and Olfson, 2008)

      Select sources:

      Kress, V.E., Gibson, D.M., Reynolds, C.A. (2004) Adolescents who self-injure: Implications and strategies for school counselors. Professional School Counseling, February.

      Mojtabai, R., and Olfson, M. (2008). Parental detection of youth’s self-harm behavior. Suicide & Life – Threatening Behavior,38(1), 60-73. Retrieved from http://search.proquest.com/docview/224878693?accountid=10267

    • Avoid displaying shock, engaging in shaming responses, or showing great pity.

      The intensely private and shameful feelings associated with self-injury prevent many from seeking treatment. Self-injures often appear in emergency rooms only when self-inflicted wounds are so severe that they require medical treatment such as stitches or bone-setting. Because so little is known about self-injury, it is often misunderstood by medical staff members who provide the initial treatment. This misunderstanding may lead to extremely inappropriate treatment, such as stitching without anesthetic or intense feelings of frustration for the provider who asks, “Why is this person hurting him or herself?” Such reactions, if expressed in shocked or punitive ways, may reinforce the self-injurious behavior and its underlying causes and encourage the self-injurer not to seek care in the future. Self-injury is most often a silent, hidden practice aimed at either squelching negative feelings or overcoming emotional numbness. Being willing to listen to the self-injurer while reserving shock or judgment encourages them to use their voice, rather than their body, as a means of self-expression.

    • Self-injury is, most often, not a suicidal gesture.

      It is important to differentiate between a self-injurious act and a suicide attempt at the outset since the two require different treatments. Mental health and counseling resources should be provided since self-injury is often a signal of underlying, unresolved distress. More long-term treatments may involve psychiatric and/or medical therapy.

    • Self-injury serves a function -- explicitly teaching more appropriate coping strategies may be one way to provide self-injurers with adaptive alternatives.

      Self-injury is most common in youth having trouble coping with anxiety, depression, or other conditions that overwhelm their capacity to regulate their emotion. It is thus important to focus on enhancing awareness of the environmental stressors that trigger self-injury and on helping individuals identify, practice, and use more productive and positive means of coping with their emotional states. Focusing on elimination of the self-injury behavior without enhacing positive means of regulating emotion may simply lead to adoption of other self-destructive behavior, such as drug abuse. Drug therapy may help in some cases as well. Some patients using prescribed drugs for depression have found a reduction in the urge to self-injure while taking these medications. Therapy may be useful in exploring the underlying causes of self-injury. A combination of the above treatments may significantly reduce or completely eliminate self-injurious behavior.

      Select sources:

      Chapman, A.L., Gratz, K.L., & Brown, M.Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behavior Research and Therapy, 44, 371-394.

      Walsh, B.W. (2005). Treating self-injury: A practical guide. New York, NY: Guilford Press.

    • Assess the safety of self-injurious practices.

      DiClemente et al. (1991) found that over one quarter of hospitalized adolescents who self-injured reported that they had shared cutting implements with others. Not only are the hazards of disease transmission or infection paramount, but bringing dangerous objects to school can lead to detention or suspension. Those who self-injure as well as those charged with detecting and intervening in self-injurious behavior need to adopt strategies for reducing the harm that can result as a consequence of sharing implements or using objects which might introduce infections.

      Select sources:

      DiClemente, R.J., Ponton, L.E., & Hartley, D. (1991). Prevalence and correlates of cutting behavior: Risk for HIV transmission. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 735-738.

    • Assess level of group involvement.

      Anecdotal evidence of self-injurious practices among groups of youth is increasingly common. Group self-injury is often a means of group bonding and membership and, as such, is undertaken with aims other than reducing anxiety or coping with overwhelming negative feeling – motivations strongly associated with “lone” self-injurious practices. These differences in motivation are likely to necessitate differences in approaches to intervention and prevention. However, because there is also is evidence that self-injurious behavior can be contagious in institutional settings and anecdotal evidence that it is also showing contagious tendencies in school settings, identifying and intervening in group self-injurious activities is important. The possibility for serious unintentional injury or infection to occur and / or for individuals who begin to self-injure as a means of group membership to develop a dependency on the practice over time augments the importance of early intervention and prevention. Identifying who is involved, the nature and lethality of the self-injurious activities used, and the purpose served for individuals and the groups constitute important first steps in effective detection and intervention.

    • Develop guidelines for detection, intervention and referral.

      Institutions, such as secondary schools and Universities should consider adopting formal guidelines for detecting and managing self-injurious behaviors. In a recent national study of University mental health staff, fewer than 1/3 of the respondents indicated that the institution for which they work possesses a set of guidelines for managing self-injurious or other depression-related behaviors but virtually all agree that it is something about which they would like additional information and guidance. In light of the fact that self-injurious behaviors appear to be increasing and somewhat “contagious”, early detection and intervention is important. Specific resources which might aid with intervention and specific treatment strategies can be located on the resources page of this website.

      Select sources:

      Whitlock, J., Eells, G., Cummings, N., & Purington, A. (2009). Nonsuicidal self-injury in college populations: Mental health provider assessment of prevalence and need. Journal of College Student Psychotherapy, 23(3), 172-183.

    • Treatment

      There are a number of modalities that therapists may use to intervene in the practice of self-injury. Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), and interventions that focus on understanding, tolerating, and accepting emotions (emotional regulation) while learning healthy use of coping skills (such as interpersonal effectiveness) are typically most helpful to those who self-injure. While there are few psychotherapeutic treatments that have been designed specifically for NSSI in adolescents, a review by Washburn et al. (2012) suggests that CBT in combination with medication adjustments can be more effective than just changing a medication. Several other studies (Miller et al., 2007; Lynch et al., 2009; Gratz & Chapman, 2009) also suggested that DBT was the most effective form of CBT because it actively targets the depressive symptoms, suicidal cognitions, and problem-solving deficits that maintain deliberate self harm. Despite DBT’s effectiveness, there is still a need to tailor treatment approaches to NSSI specifically. DBT was initially developed to treat individuals with Borderline Personality Disorder (BPD), considering self-injury only as a symptom of BPD. Mentalization-based treatments, those which help individuals who self-injure to learn how to separate their own thoughts and feelings from those of others, also show promise. A recent meta-analysis by Calati and Philippe (2016) examining multiple psychotherapies suggests that mentalization-based treatment was the only intervention effective in reducing NSSI. Most treatment providers who are familiar with self-injury will use these approaches in ways that they find are most likely to help their client. Collaborative, strength-based approaches are also popular among some self-injury treatment specialist. These modalities integrate aspects of DBT and CBT but also focus strongly on shared goal-setting with the client, engaging family and/or other members of the client’s social ecology as a means of support, and on emphasizing existing or easy to develop strengths in the recovery process. Further research is still needed to improve efficacy of treatment specifically in adolescents who engage in NSSI without Borderline Personality Disorder

      Select sources:

      Calati, R., and Philippe, C. (2016). Is Psychotherapy Effective for Reducing Suicide Attempt and Non-Suicidal Self-Injury Rates? Meta-Analysis and Meta-Regression of Literature Data. Journal of Psychiatric Research, 79: 8–20. doi: 10.1016/j.jpsychires.2016.04.003

      Gratz, K.L. and Chapman, A.L. (2009) Freedom from Self-Harm: Overcoming Self-Injury with Skills from DBT and Other Treatments. Oakland, CA: New Harbinger Publications.

      Whitlock, J. and Selekman, M. (2014). Chapter 8: Prevention of Nonsuicidal Self Injury. In M.K. Nock (Ed.), The Oxford Handbook of Suicide and Self-injury.

      Walsh, B. W. (2012). Treating self-injury: A practical guide. Guilford Press.

      Lynch, T.R., and Cozza, C. (2009) Nock 2009 Understanding Nonsuicidal Self-Injury: Origins, Assessment, and Treatment. Edited by M. Nock. American Psychological Association Press, Chapter 12 and 13.

      Miller, A.L., Rathus, J.H., and Linehan, M.M. (2007). Dialectical Behavior Therapy with Suicidal Adolescents. New York, NY: Guilford Press.

      Walsh, B. W. (2012). Treating self-injury: A practical guide. Guilford Press.

      Washburn, J.J., Richardt, S.L., Styer, D.M, Gebhardt, M., Juzwin, K.R., Yourek, A., and Aldridge, D. (2012). Psychotherapeutic approaches to non-suicidal self-injury in adolescents. Child Adolesc Psychiatry Ment Health, 6(14). doi: 10.1186/1753-2000-6-14

  • Prevention

    Self-injury prevention is a slow growing area of research. Only one prevention program, the Signs of Self-injury Program developed by Screening for Mental Health with Dr. Barry Walsh, has been evaluated. There will undoubtedly be more evidence-based practices and programs on the horizon, but for now we can begin to craft possible strategies by acknowledging dominant reasons for initiating and maintaining self-injurious practices and from lessons in related fields, such as disordered eating.

    • Enhance capacity to cope and regulate emotional perceptions and impulses. Inability to find alternate satisfying ways of coping with strong negative feelings is a highly consistent motivation for engaging in self-injury. Indeed, one of the most common reasons for ceasing the behavior given in our recent student survey is the adoption of other coping mechanisms. It thus seems logical that effective prevention (and treatment) approaches will include a focus on enhancing individuals’ capacity to cope with adversity. Indeed, this focus is one of the elements of Dialectical Behavior Therapy (DBT) – one of the more common and effective treatment approaches used with self-injurious behavior. Broad agreement among mental health professionals that capacity to cope is declining in the general population of adolescent and young adults suggests that enhancing capacity to cope may also be a useful part of universal and targeted prevention approaches. Building on existing strengths and exploiting opportunities within institutional curriculum to help youth explore diverse methods of coping with negative feelings may help accomplish this objective.
    • Enhance social connectedness. Those who practice self-injurious behavior also report high levels of perceived loneliness, less dense social networks, less affectionate relationships with their parents, and a history of emotional and/or sexual abuse. They are also more likely to suffer from diminished self-esteem, feelings of invisibility, and shame. Indeed, feeling invisible and inauthentic are common themes among self-injurious students we have interviewed for our studies. Approaches in which adolescents and adults are aided in recognizing and building on existing strengths, in reaching out to and connecting way with others in an authentic and meaningful way, and in participating in activities which allow them to feel meaningfully linked to something larger than themselves may help to shape a more positive view of the self. This may ultimately lessen reliance on potentially damaging coping mechanisms.
    • Avoid strategies aimed primarily at raising knowledge of forms and practices. Strategies aimed primarily at raising knowledge generally use single-shot or knowledge enhancement approaches to educate universal or targeted groups of youth about specific risk behaviors, practices, forms and consequences. In their review of eating disorder prevention strategies and research Levine and Smolak (2005) and Heath (2014) summarize research which suggests that single-shot awareness raising strategies (e.g., educational assemblies or workshops) are, at best, either not effective or only effective in raising short term knowledge and are, at worst, linked to increases in the behavior they intend to stop. Adverse effects were particularly evidenced in high school and college populations. Repeated and rigorous evaluation of the popular DARE program aimed at reducing drug use among youth has also been shown to be ineffective and, at worst, harmful. In many ways, these findings are consistent with common sense when regarded in the context of developmental processes – adult attention to specific risk behaviors, particularly if highly informative but of short duration or thoughtful follow-up, can be scintillating to adolescents interested in seeking adult attention or taking risks. Strategies which raise awareness about underlying factors (e.g. role of media or the cultural thinness ideal in promoting eating disorders) are not the same as those which simply educate about the prevalence, forms and practices associated with a specific issue and are likely to be more effective in positively raising awareness.
    • Equip staff and faculty to recognize and respond to signs of self-injurious behavior. Although it may be unwise to share detailed information about self-injurious behavior with large groups of youth, adults likely to encounter adolescents or young adults who engage in self-injurious behavior do need to know signs and symptoms. They also need to know what to do if they suspect or know someone is using self-injurious practices. Toward this end, raising awareness among adults as well as establishing protocols for referral is helpful for those who work directly with youth.
    • Prevention programs should be multilevel and interdisciplinary whenever possible. Prevention programs have been found to be more effective when they combine different components of the individual’s social network that cross domains (personal, psychological, academic, physical).
    • Focus on increasing staff and student capacity to recognize distress. As with many risk behaviors, our research shows that peers are most often the first to know or suspect that a friend is using self-injurious practices. As such, peers constitute the “front line” in detection and intervention. In light of the above recommendation to avoid awareness raising strategies about self-injurious behaviors with youth, we advocate concentrating effort on assisting young people recognize general symptoms of distress in their peers. Self-injurious behavior could be one of several categories of behaviors and perceptions assessed (mixing both positive and negative indicators avoids a solely deficit-based slant to findings) such as perceived wellbeing, eating disorders,life satisfaction, depression, relationships with adults, suicidality, etc. Additionally, while a few examples might be useful in explaining what is meant by self-injury, detailed description of forms could be avoided. In addition to educating about how to recognize distress, students could be encouraged to seek assistance and coached on specific strategies for getting help.
    • Promote and advertise positive norms related to help-seeking and communication about mental and emotional status and needs. It often requires more than a program or two to change embedded patterns. The tendency for peers to show loyalty to friends rather than to adults is strong (and, in many ways, fundamentally socially adaptive). Peers with knowledge of a friend’s dangerous behavior are may be unlikely to share that knowledge with an adult without concentrated effort by adults to alter adolescent and adult norms about help-seeking and communication — particularly communication between adolescents and adults. Strategies focused on altering community norms in social support and help seeking have been shown to be exceptionally effective in suicide prevention in a general population of adults in the US Air Force. Address sources of stress in external environment. The relationship between the sheer volume of stress or risk factors individuals confront and negative outcomes is well documented. Researchers have overwhelmingly shown that the more risk factors an individual confronts, the less like they are to thrive and the more likely they are to exhibit negative behaviors and attitudes. The capacity to manage multiple stressors simultaneously is particularly difficult for children and adolescents who attempting to successfully meet core developmental needs as well. Although empirically impossible to verify, the argument that contemporary children and youth confront an increasingly complex and varied set of stress and risk factors when compared to previous generations is persuasive and may be one reason for increases in rates of mental illness, including self-injurious behavior. If so, as Levine and Smolak (2005) argue for eating disorders, targeting environmental sources of stress may be a fundamentally more effective prevention strategy than targeting individual youth deemed to be at risk for self-injurious or other concerning behaviors.
    • Educate youth to understand the role media plays in influencing behavior. Media has consistently been shown to affect child and adolescent behavior in profound ways. Examination of the possible role media plays in spreading the idea of self-injurious behavior is one of the projects undertaken as part of this study program. Our preliminary findings support the assumption that images, songs, and news articles in which self-injurious behavior is featured has increased significantly over the past decade. As Brumberg (1992) has argued for eating disorders, highly visible public displays of self-injurious behavior may add potentially lethal behaviors to the repertoire of young people exploring identity options. Similarly Heath et al. (2014) suggest that explicit NSSI materials including personal stories, video projects, visual images may serve as triggers. Helping adolescents and young adults become critical consumers of media may lessen their vulnerability to adoption of glamorized but fundamentally poor coping strategies

    For downloadable CRPSIR resources click here

    Select sources:

    Brown, J.H., D’Emidio-Caston, M., & Pollard, J.A. (1997). Students and substances: Social power in drug education. Educational Evaluation and Policy Analysis, 19, 65-82.

    Chapman, A.L., Gratz, K.L., & Brown, M.Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behavior Research and Therapy, 44, 371-394.

    DuRant, D.H., Rich, M., Emans, S.J., Rome , E.S., Allred, E., Woods, E.R., et al. (2003). The relationship between watching professional wrestling on television and engaging in health risk behaviors among young adolescents. Journal of Adolescent Health, 30, 114.

    Levine, M. & Smolak, L. (2005). The prevention of eating problems and eating disorders: Theory, research, and practice. New Jersey: Erlbaum.

    Garbarino, J. (1995). Raising children in a socially toxic environment. San Francisco: Jossey-Bass.

    Knox, K.L., Litts, D.A., Talcott, G.W., Feig, J.C., & Caine, E.D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the U.S. Air Force: Cohort study. British Medical Journal, 327, 1376-1381.

    Walsh, B.W. (2005). Treating self-injury: A practical guide. New York, NY: Guilford Press.

    Whitlock, J.L., Wyman, P., and Moore, S. (2014). Connectedness and suicide prevention in adolescence. Suicide and Life Threatening Behavior. 44(3) 247-272. doi: 10.1111/sltb.12071

    Heath, N., Toste, J., Dell-MacPhee, S. (2014). Chapter 22: Prevention of Nonsuicidal Self Injury. In M.K. Nock (Ed.), The Oxford Handbook of Suicide and Self-injury. Oxford University Press.

    Kruzan, K. P., & Whitlock, J. L. (2019). Prevention of Non-Suicidal Self-Injury. In (Ed) J. Washburn, Nonsuicidal Self-Injury: Advances in Research and Practice. Routledge.

    Kruzan, K. P., & Whitlock, J. (2019). Processes of Change and Nonsuicidal Self-Injury: A Qualitative Interview Study With Individuals at Various Stages of Change. Global Qualitative Nursing Research, 6, 2333393619852935.

  • References

    • Bhugra, D., Singh, J., Fellow-Smith, E., & Bayliss, C. (2002). Deliberate self-harm in adolescents. A case study among two ethnic groups. European Journal of Psychiatry, 16(3),
      145-151.
    • Boyce, P., Oakley-Browne, M.A., & Hatcher, S. (2001). The problem of deliberate self-harm. Current Opinion in Psychiatry, 14, 107-111.
    • Briere, J., & Gil, E. (1998). Self-mutilation in clinical and general population samples: Prevalence, correlates, and functions. American Journal of Orthopsychiatry, 68(4), 609-620
    • Brodsky, B.S., Cloitre, M., & Dulit, R. A. (1995). Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder. American Journal of Psychiatry, 152(12), 1788-1792.
    • Brown, J.H., D’Emidio-Caston, M., & Pollard, J.A. (1997). Students and substances: Social power in drug education. Educational Evaluation and Policy Analysis, 19, 65-82.
    • Chapman, A.L., Gratz, K.L., & Brown, M.Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behavior Research and Therapy, 44, 371-394.
    • DiClemente, R.J., Ponton, L.E., & Hartley, D. (1991). Prevalence and correlates of cutting behavior: Risk for HIV transmission. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 735-738.
    • DiLazzero, D.B. (2003). Addressing self-injury in a college environment: A psychoeducational program. University of Hartford, Hartford.
    • DuRant, D.H., Rich, M., Emans, S.J., Rome , E.S., Allred, E., Woods, E.R., et al. (2003). The relationship between watching professional wrestling on television and engaging in health risk behaviors among young adolescents. Journal of Adolescent Health,30,114.
    • FACTIVA [database online]. Dow Jones Reuters Business Interactive LLC. Accessed April 10, 2006.
    • Farber, S. K. (1997). Self-medication, traumatic reenactment, and somatic expression in bulimic and self-mutilating behavior. Clinical Social Work Journal, 25(1), 87-106.
    • Favazza, A.R. (1996). Bodies under siege: Self mutilation and body modification in culture and psychiatry (2 ed.). Baltimore, MD: Johns Hopkins University Press.
    • Favazza, A.R., & Conterio, K. (1989). Female habitual self-mutilators. Acta Psychiatrica Scandinavica, 79, 283-289.
    • Garrison, C.Z., Addy, C. L., McKeown, R.E., & Cuffe, S.P. (1993). Nonsuicidal physically self-damaging acts in adolescents. Journal of Child & Family Studies, 2, 339-352.
    • Gratz, K.L. (2001). Measurement of deliberate self-harm: Preliminary data on the deliberate self-harm inventory. Journal of Psychopathology and Behavioral Assessment, 23(4), 253-263.
    • Gratz, K.L., Conrad, S.D., & Roemer, L. (2002). Risk factors for deliberate self-harm among college students. American Journal of Orthopsychiatry, 72, 128-140.
    • Hawton, K., Fagg, J., Simkin, S., Bale, E., & Bond, A. (2000). Deliberate self-harm in Oxford, 1985-1995. Journal of Adolescence, 23(1), 47-55.
    • Hawton, K., Rodham, K., Evans, E. (2006). By their own young hand: Deliberate self-harm and suicide ideas in adolescence. Kingsley: London.
    • Heath, N.L., Toste, J.R., & Beettam, E. (2006). “I am not well-equipped”: High school teachers’ perceptions of self-injury. Canadian Journal of School Psychology 21(1-2), 73-92.
    • Huesmann, R.L., Moise-Titus, J. Podolski C.L., & Eron, L.D. (2003). Longitudinal relations between children’s exposure to TV violence and their aggressive and violent behavior in young adulthood: 1977 – 1992. Developmental Psychology, 39(2).
    • Klonsky, E.D. (2007). The functions of deliberate self-injury. A review of the evidence. Clinical Psychology Review, 27, 226-239.
    • Knox, K.L., Litts, D.A., Talcott, G.W., Feig, J.C., & Caine, E.D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the U.S. Air Force: Cohort study. British Medical Journal, 327, 1376-1381.
    • Kokaliari, E. (2004). Deliberate self-injury: An investigation of the prevalence and psychosocial meanings in a non-clinical female college population. Dissertation. Smith College.
    • Klonsky, E.D., Oltmanns, T.F., & Turkheimer, E. (2003). Deliberate self-harm in a non-clinical population: Prevalence and psychological correlates. American Journal of Psychiatry, 160, 1501-1508.
    • Kress, V.E., Gibson, D.M., Reynolds, C.A. (2004) Adolescents who self-injure: Implications and strategies for school counselors. Professional School Counseling, February.
    • Laye-Gindhu, A. & Schonert-Reichl, K.A. (2005). Nonsuicidal self-harm among community adolescents: Understanding the “whats” and “whys” of self-harm. Journal of Youth and Adolescence, 34(5), 447-457.
    • Levine, M. & Smolak, L. (2005). The prevention of eating problems and eating disorders: Theory, research, and practice. New Jersey: Erlbaum.
    • Lynam, D.R, Milich, R, Zimmerman, R., Novak, S. P., Logan , T. K., Martin, C., Leukefeld, C., & Clayton, R. (1999).
    • Project DARE: No effects at 10-year follow-up. Journal of Consulting and Clinical Psychology,67(4).
    • Marshall, H. & Yazdani, A. (1999). Locating culture in accounting for self-harm amongst Asian young women. Journal of Community Applied Social Psychology, 9(6), 413-433.
    • Martin, G., Rozanes, P., Pearce, C., & Allison, S. (1995). Adolescent suicide, depression and family dysfunction. Acta Psychiatrica Scandinavica, 92, 336-344.
    • Matthews, P.C. (1968). Epidemic self-injury in an adolescent unit. International Journal of Social Psychiatry, 14:125-133.
    • Muehlenkamp, J.J., & Gutierrez, P.M. (2004). An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide & Life-Threatening Behavior, 34, 12-24.
    • Nock, M.K., Joiner, T.E., Gordon, K.H., Lloyd-Richardson, E., & Prinstein, M.J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144(1), 65-72.
    • Purington, A., Whitlock, J., & Pochtar, R. (2010). Non-suicidal self-injury in secondary schools: A descriptive study of prevalence, characteristics, and interventions. Manuscript submitted for publication.
    • Radcliffe, J. (2004, March 28). Self-destructive “cutters” live their lives on the edge. Los Angeles Daily News.
    • Rosen, P.M., & Heard, K.V. (1995). A method for reporting self-harm according to level of injury and location on the body. Suicide & Life-Threatening Behavior, 25(3), 381-385.
    • Rosen P.M., Walsh B.W. (1989). Patterns of contagion in self mutilation epidemics. American Journal of Psychiatry, 146(5): 656-658.
    • Ross, S., & Heath, N.L. (2003). Two models of adolescent self-mutilation. Suicide & Life-Threatening Behavior, 33(3), 277-287.
    • Rutter, M. (1989). Pathways from childhood to adult life. Journal of Psychology and Psychiatry, 30, 23-51.
    • Sameroff, A.J. (1993). Models of development and developmental Risk. In C. H. Zeanah (Ed.), Handbook of Infant Mental Health. New York, NY: Guilford Press.
    • Skegg, K. (2005). Self-harm. Lancet, 366, 1471-1483.
    • Taiminen T.J., Kallio-Soukainen K., Nokso-Kovisto H., Kaljonen A., Helenius H. (1998). Contagion of deliberate self-harm among adolescent inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 37(2): 211-217.
    • Walsh, B.W. (2005). Treating self-injury: A practical guide. New York, NY: Guilford Press.
    • Whitlock, J., Eells, G., Cummings, N., & Purington, A. (2009). Nonsuicidal self-injury in college populations: Mental health provider assessment of prevalence and need. Journal of College Student Psychotherapy, 23(3), 172-183.
    • Whitlock, J.L., Eckenrode, J.E. & Silverman, D. (2006). The epidemiology of self-injurious behavior in a college population. Pediatrics, 117(6).
    • Whitlock, J.L. & Knox, K. (2007). The relationship between suicide and self-injury in a young adult population. Archives of Pediatrics and Adolescent Medicine. 161(7).
    • Whitlock, J.L., Muehlenkamp, J., Eckenrode, J. (2008). Variation in non-suicidal self-injury: Identification of latent classes in a community population of young adults. Journal of Clinical Child and Adolescent Psychology. 37(4). 725-735.
    • Whitlock, J., Muehlenkamp, J., Purington, A., Eckenrode, J., Barreira, J., Abrams, G.B., Marchell, T., Kress, K., Girard, K., Chin, C., Knox, K. (in press) Non-suicidal self-injury in a college population: General trends and sex differences. Journal of American College Health.
    • Whitlock, J.L., Purington, A., Gershkovich, M. (2009). Influence of the media on self injurious behavior. In Understanding non-suicidal self-injury: Current science and practice, edited by M. Nock. American Psychological Association Press. 139-156.
    • Winchel, R.M. & Stanley, M. (1991). Self-injurious behavior: A review of the behavior and biology of self-mutilation. American Journal of Psychiatry, 148(3), 306-317.
    • Young People and Self-Harm: A National Inquiry. (2004). What do we already know? Prevalence, risk factors & models of intervention. Retrieved from http://www.selfharmuk.org

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Bronfenbrenner Center for Translational Research