Content Warning: This article contains a discussion about self-harm and suicide that may be upsetting to some readers.
The beginning of March marked the recognition of Self-Injury Awareness Day. To help demystify the nuances of non-suicidal self injury (NSSI), two of our experts with the South Southwest Mental Health Technology Transfer Center — Jennifer Baran-Prall (LCSW) and Nadia Maynard (MSW, SHRM-SCP) — sat down for a conversation on how clinical thinking around NSSI has changed over time, and how we as a community can provide support.
So where should we start? Should we just jump right in with the difference between non-suicidal self-injury (NSSI) and suicide attempts?
Jennifer Baran-Prall (JBP): This is a really good conversation to have. Both concepts are hard to talk about. People find them to be a little uncomfortable. Suicide and NSSI are different, and yet I also think there could be a bridge in between the two. That’s why it’s good to talk about them together. What we need to talk about is someone who is trying to get help. They are looking for ways to ease or release suffering. And the connection between Suicide and NSSI comes in when you have a self-harming behavior that you have been using to cope, and it’s become something that you’ve acclimated to, then …
Nadia Maynard (NM): The intensity grows
JBP: The intensity grows and it could maybe lead to something worse on accident, something …
JBP: Correct. When you think about suicide, the distinction between it and NSSI would be there is an intentional wanting to die. But when you look at NSSI, the intent isn’t to die. It’s actually to live healthier and feel better. But most people will, at first blush, feel like that isn’t true. What’s really important is that we do have a real, kind, non-judgmental discussion about it. Because then the discussion becomes, “Well, how can we look at other ways to help cope and be loving to yourself?”
NM: The other piece of NSSI is that you are communicating that your feelings are really intense and that you need to do this in order to release some of those feelings. When I first started working in the field of mental health, NSSI was seen as a maladaptive coping strategy, and people who engaged in it were framed as doing something bad or just trying to get attention. Really, the truth is so far from that. That is not the way we look at it anymore. Our thoughts and feelings around it have evolved overtime and that’s why it is so important talk about the nuances between NSSI and suicide. Like Jennifer said, there’s a bridge of increasing intensity, because you don’t have any other kind of replacement strategies, and the danger can increase.
Is NSSI not thought of as attention-seeking in any sense anymore? Is it ever used as a way to ask for help by hoping someone would notice the signs?
NM: There is such a strong overlap for having a trauma history and engaging in self-harm. We used to look at all these things as black or white, and I think it’s about bringing it back more to center to understand the nuance of this behavior. That evolution in thinking is about acknowledging NSSI as a survival skill of some sort. It’s a way to navigate a very difficult situation and very intense feelings.
JBP: I think that’s a really good discussion to have. NSSI can be a way to have a discussion about getting help. But when we say attention-seeking, I think there is a negative connotation with that. Someone who is self-harming is doing it for release, but then if you are doing it in a way that someone can see, you are connecting with someone. That is a way of communicating that you are having a rough time. You may not have the words for it, but you are looking for someone that is not going to judge you and will react in a healthy way by getting assistance or talking to me about it.
NM: And you can explore intention at that point, right?
JBP: Right, that’s when you’d do a risk assessment. Or if you aren’t trained, you’re going to get that person immediately to someone that can help. Saying “I’m worried about you” — just that to me is an intervention. I think anyone can do that in a compassionate way.
NM: You’re leaving the door open for compassionate discussions.
JBP: With self-harm, we want to get a replacement type behavior as early as we can. With a healthy, adaptive behavior, the less risk you are going to be in for self-harm in general, but then also, further down the road, less risk for a mistake or accidental suicide. It does happen. We all need to help people talk about it so that they aren’t stigmatized. And also, to help those who love someone who self-harms, because that can be very hard, too.
NM: And let them know that they are not alone. Knowing more about NSSI has allowed me to take stock of my own reactions and feelings around it, and then realize that I need to be open and compassionate and investigate what could potentially be going on and, more importantly, connect with this person. For everyone, Mental Health First Aid trainings are an amazing resource. It gives you the strategies to asses what’s going on and how to use the destigmatizing language. It gives you the ability to intervene in a crisis in a way that anyone could do it. Anyone can take this training and walk away feeling like, “Okay, now if I’m faced with someone who is self-harming, I will be able to engage them in a helpful way.” And I think that’s important for everyone to feel. It needs to be all of us. We need to be a community of people who understand and destigmatize mental health.
JBP: Right. How I would approach it is that I would actually validate the crisis. You are in crisis. You are doing something because you’re in crisis. You are feeling emotionally dysregulated. I want to acknowledge you are in a very difficult space and I get it and I am sorry you are feeling that way. Now, let’s get you feeling better. It’s more of an acknowledgement, I think, of that it is what it is and not seeing it as good or bad.
NM: There is such a strong overlap for having a trauma history and engaging in self-harm. We used to look at all these things as black or white and I think it’s about bringing it back more to center to understand the nuance of this behavior. We need to create space for ambiguity. A big part of our own stigma is our own discomfort, right? It’s our own discomfort that’s stopping us from having these conversations, from having the ability to create space for ambiguity for uncertainty. I think that our own stigma and barriers come up and we would much rather put it in a nice neat box. Because there is some ambiguity around NSSI and suicide, it is important to be able to ask, “Are you feeling suicidal?” if you notice self-harming behavior. If they say yes, then the conversation can continue to whether they have a plan or not, and linking them to critical resources, as well as being sure to never leave them alone. Again, going through the Mental Health First Aid training can really help prepare you for having that conversation. But providing the space for that conversation and not holding back helps take the shame away, and helps them know they are not alone.
We need to create space for ambiguity. A big part of our own stigma is our own discomfort, right? It’s our own discomfort that’s stopping us from having these conversations, from having the ability to create space for ambiguity for uncertainty.Nadia Maynard (MSW, SHRM-SCP)
JBP: I think it’s also okay to know that when you have that conversation, you shouldn’t have to weigh and measure words. It’s okay to say, “I’m worried,” or, “That scared me. I am scared for you.” Those are okay things to say. There is not a perfect conversation and you are really letting someone know you care about them and you’re genuinely worried.
NM: And sometimes we are not ready to talk about where those feelings are coming from. It may feel really dangerous and unsafe to go there. An app (Calm Harm for one) can help you get to a place where eventually you can talk about what the sources of the self-harming behavior might be. Overall, we want to be able to talk about self-harm, in a kind, compassionate way, without judgement, and integrating all our trauma informed principles.
Are you or someone you know feeling suicidal or struggling with non-suicidal self-injury? The resources below can provide help 24/7.
National Suicide Prevention Lifeline – The national suicide hotline is staffed around the clock and can be reached at 1-800-273-TALK (1-800-273-8255).
Integral Care Crisis Line – The Integral Care 24/7 helpline is based in Austin, TX and can be reached at 512-472-HELP (512-472-4357).
Calm Harm – A free app available for Apple and Android that helps users resist or manage the urge to self-harm.
To learn more about the Texas Institute for Excellence Mental Health’s work with the South Southwest Mental Health Technology Transfer Center, visit the South Southwest MHTTC’s website.