Understanding and Addressing Self-Injury:

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Examining the Spectrum. from Non-Suicidal Self-Injury . to Suicide Finality. Critical Issues Conference, October 9, 2015. Michael Riquino, LCSW. Preface/Warnings. I talk really fast – it’s not because I’m nervous, it’s just the way I talk. ID: 591996 Download Presentation

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Understanding and Addressing Self-Injury:

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Understanding and Addressing Self-Injury: Examining the Spectrumfrom Non-Suicidal Self-Injury to Suicide Finality

Critical Issues Conference, October 9, 2015

Michael Riquino, LCSW



I talk really fast – it’s not because I’m nervous, it’s just the way I talk

References to celebrities or pop culture are meant to inform – not to glamorize

I have a macabre sense of humor – I apologize for any unintentional crassness

This PowerPoint is available on my website:



Spectrum/Overlapping Constructs

And the importance of considering semantics


Transdiagnostic Perspective

Self-injury is diagnostically heterogeneous:

Mood disorders (


, bipolar)

Anxiety disorders (GAD,



Personality disorders (


, avoidant)

Eating disorders (







A note about child maltreatment:


% of individuals engaging in self-injury report some form of childhood



Self-Harm as an Umbrella Term


What is Self-Injury?

Deliberate or intentional destruction of body tissue

without suicidal intent

Other common labels include deliberate self-harm, parasuicidal behavior, self-mutilation, non-suicidal self-injury, and cutting

A note about use of the term “cutter”


Forms of Self-Injury

Most common forms:cutting (70-97%)banging or hitting (21-44%)burning (15-35%)75% of individuals who engage in self-injury employ more than one method

Other forms include:

bone breaking







biting and scratching

interfering with the healing of




Prevalence of Self-Injury

9% - 17% of adolescents

in community samples

28% - 46% of high school students reported at least one instance of self-injury in the last year

40% - 80% of adolescent psychiatric patients

Average age of onset

between 12 and 15 years old (

as young as 6 and up to 24



Sociocultural Context

Tattoos and piercings becoming mainstream

Mormonism (58%) and Catholicism (10%)

Please note, religion is typically a protective factor

Olympic athletes – Kerri


, gold medalist

Ritual scarification, fasting and meditation

Eating disorders are no longer trendy

Please note, use of the word “trendy” is reductive


Functions of Self-Injury

Most common functions:Emotion regulationAnti-dissociation/numbnessAnti-suicideSelf-punishmentInterpersonal influence*

Other functions include:Sense of controlConnecting mind and bodySensation-seekingAvoidance of internal painDistraction from flashbacks

*Less than 4% of adolescents who self-injure do so to get attention, yet this is the most common reason given by parents, teachers, and other adults to explain the behavior


Self-Injury and Suicide

50% of individuals in community samples and 70% of inpatients who engage in self-injury report having attempted suicide at least once

A paradoxical relationship:



-injury simultaneously serves as a coping mechanism for dealing with suicidal ideation and is a correlate

of past

and possible future suicide attempts


Self-Injury and Social Media

The internet may be used as a support network and a coping mechanism, and can connect people who are socially isolatedThe internet may negatively influence vulnerable youth:Normalization of self-injurious behaviorsAccess to suicide content and violent imageryCreates a communication channel for bullying/harassmentExposure to self-harm on the internet may be associated with potentially more dangerous methods of self-harm


, K.,


, K.,


, V., Stewart, A.,


, S., & Montgomery, P. (2013). The power of the web: A systematic review of studies of the influence of the internet on self-harm and suicide in young people




: 10.1371/journal.pone.0077555


Combating Stereotypes

Stereotypes are grounded in truth, but are ultimately false as they cannot be ascribed to any particular individual

Self-injurious behaviors are overly associated with “emo” or “scene” culture due to the lyrical content of such musical artists and the ascription of self-injury as a fad among “emos”


Suicide Variables/Patterns

Gender differences: Frequency vs. Lethality

Vulnerable populations

Children and adolescents

Elderly persons (19% of suicides vs. 12 % of population)

LGBTQ youth (30% of suicides vs. 10% of population)

Native Americans and other ethnic minorities

Religiosity as a protective factor or a risk factor


Risk Factors & Protective Factors

Risk Factors vs. Warning Signs

Warning signs indicate an immediate risk of suicide whereas risk factors indicate someone is at heightened risk for suicide, but indicate little or nothing about immediate risk

Warning signs are only applicable to individuals whereas risk factors are found in individuals and communities

Risk factors include prior suicide attempts, mood disorders, substance abuse, psychosis, and access to lethal means

Warning signs include threatening to hurt or kill oneself, seeking the means to kill oneself, hopelessness, increasing substance use, and dramatic mood changes


Risk Factors & Protective Factors

Protective Factors

Coping Skills and Personal Traits

Decision making, anger management, conflict resolution, problem solving and other coping skills

A sense of personal control over actions

A healthy fear of risky behavior and pain

Hope for the future


Religious/spiritual beliefs about the meaning and value of life

Positive relationships with family, friends, or other caring adults

Responsibilities at home or in the community

Physical health and a safe/stable home environment


Columbia-Suicide Severity Rating Scale

Suicidal ideation

Wish to be dead, e.g., “Have you ever thought about being dead or what it would be like to be dead? Have you ever wished you were dead or wished you could go to sleep and never wake up? Do you wish you weren’t alive anymore?”

Non-specific active suicidal thoughts, e.g., “I’ve had thoughts about killing myself”

Active suicidal ideation with any means (not plan) without intent to act

Active suicidal ideation with some intent to act, without specific plan

Active suicidal ideation with specific plan and intent


Columbia-Suicide Severity Rating Scale

Suicidal behavior

Actual attempt, i.e., a potentially self-injurious act with at least some wish to die

as a result of act

Has subject engaged in non-suicidal self-injurious behavior?

Has subject engaged in self-injurious behavior, intent unknown?

Interrupted attempt, i.e., when the person is interrupted by any outside circumstance from starting the potentially self-injurious act; if not, actual attempt would have occurred

Aborted attempt, i.e., when person begins to take steps toward making suicide attempt, but stops themselves

Preparatory acts or behavior, i.e., acts or preparation towards imminently making a suicide attempt


Columbia-Suicide Severity Rating Scale

Actual lethality/medical damage

0 = No physical damage or very minor damage (e.g., surface scratches)

1 = Minor physical damage (e.g., superficial burns; mild bleeding)

2 = Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-degree burns; bleeding of major vessel)

3 = Moderately severe physical damage;

medical hospitalization and likely intensive care required (e.g., comatose with reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures)

4 = Severe physical damage;

medical hospitalization with intensive care required (e.g., comatose without reflexes; third-degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area)

5. Death

Potential lethality (if actual lethality = 0)


Summing up the C-SSRS

Suicidal ideation has four “parts” or “levels”

Thoughts of wanting to die

Non-specific thoughts of killing self

Suicide plans

Intent to die

Somewhat reductive, but helpful for conceptualization and communicating with adolescents

Stanley Brown Safety Template


Spectrum/Overlapping Constructs


Based on self-report

Subject to decay


Forms of self-injury

Forms of suicide

Risk of lethality


Take-Home Messages

Respond with emotional neutrality –

Don’t freak out!

Reflect, Validate, Problem-solve

Addressing guilt vs. shame

Guilt can be

constructive because it

motivates us to change our behavior

Shame is always

destructive because it

contributes to feelings of worthlessness

Setting boundaries for physical safety

Focusing on underlying thoughts and feelings


Ten Years Later

Being present in the moment – the promise and potential of mindfulness

The importance of self-acceptance and self-compassion

The potential for parents/caregivers to be the greatest sources of support – the role of psychoeducation

Initial assessments – instilling hope


Suicide Prevention Resources



Suicide Prevention Resource Center


Prevention Lifeline


National Alliance on Mental Illness


American Foundation for Suicide Prevention


Substance Abuse and Mental Health Services Administration



Online Self-Injury Resources

Cornell Research Program


To Write Love On Her Arms





Secret Shame


The Trevor Project


Rape, Abuse, & Incest National Network



Self-Injury Book Resources

Treating Self-Injury




The Oxford Handbook of Suicide and Self-Injury

Bodily Harm


Karen Conterio and Wendy Lader

A Bright Red Scream

by Marilee Strong

Helping Teens Who Cut

By Michael Hollander


by Steven Levenkron

Bodies Under Siege

by Armando Favazza


Selected References

Conterio, K., Lader, W., & Bloom, J.K. (1998).

Bodily harm: The breakthrough healing program for self-injurers

. New York, NY: Hyperion.

Gratz, K.L. (2003). Risk factors for and functions of deliberate self-harm: An empirical and conceptual review.

Clinical Psychology: Science and Practice, 10,

192-205. doi: 10.1093/clipsy/bpg022.

Hollander, M. (2008).



who cut: Understanding and ending self-injury

. New York, NY: The Guilford Press.

Klonsky, E.D. (2007b). The functions of deliberate self-injury: A review of the evidence.

Clinical Psychology Review, 27,

226-239. doi:10.1016/j.cpr.2006.08.002.

Klonsky, E.D., & Moyer, A. (2008). Childhood sexual abuse and non-suicidal self-injury: Meta-analysis.

The British Journal of Psychiatry, 192,

166-170. doi: 10.1192/bjp.bp.106.030650.

Klonsky, E.D., & Muehlenkamp, J.J. (2007). Self-injury: A research review for the practitioner.

Journal of Clinical Psychology, 63,

1045-1056. doi: 10.1002/jclp.20412.

Lang, C.M., & Sharma-Patel, K. (2011). The relationship between childhood maltreatment and self-injury: A review of the literature on conceptualization and intervention.

Trauma, Violence, & Abuse, 12,

23-37. doi: 10.1177/1524838010386975.

Nock, M.K., Teper, R., & Hollander, M. (2007). Psychological treatment of self-injury among adolescents.

Journal of Clinical Psychology, 63,

1081-1089. doi: 10.1002/jclp.20415.

Polk, E., & Liss, M. (2009). Exploring the motivations behind self-injury.

Counselling Psychology Quarterly, 22,


Spinhoven, P., Slee, N., Garnefski, N., & Arensman, E. (2009). Childhood sexual abuse differentially predicts outcome of cognitive-behavioral therapy for deliberate self-harm.

The Journal of Nervous and Mental Disease, 197,


Strong, M. (1998).

A bright red scream: Self-mutilation and the language of pain

. New York, NY: Penguin Books.

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