You Can’t Know If You Don’t Ask: How to Assess Nonsuicidal Self-Injury
by Sarah E. Victor, PhD
Reprinted with permission from “Young People: Self-Injury” issue of Visions: BC’s Mental Health and Addictions Journal, 13(2), produced by the Canadian Mental Health Association’s BC Division on behalf of BC Partners for Mental Health and Addictions Information. To access other helpful articles in the issue, visit www.heretohelp.bc.ca/visions. There, you can also sign up to receive the quarterly magazine free of charge by email or hard copy. Visions is written to be accessible to members of the public and providers alike.
Many teens who self-injure do not get the help they need, even when they reach out to others. A recent study of high school students found that 83% of self-injuring teens asked for help for an emotional or behavioural problem, but only 59% told someone about their self-injury, and less than 10% talked about self-injury with an adult.1
This means that no news is not good news when it comes to a youth who may be struggling! If you’re worried that a teen or young adult in your life may be self-injuring, the best thing to do is ask him or her directly.
Some people worry that asking about self-injury will “make” people start self-injuring. Thankfully, research shows that asking about self-injury doesn’t cause an individual to self-injure, nor does it make an existing situation worse.2,3 The same is true when it comes to talking about suicidal thoughts and actions: asking about a possible behaviour doesn’t cause someone to engage in the behaviour.4
But how can you start a conversation with someone about such a difficult topic? You might feel awkward, uneasy or nervous about having this kind of discussion. That’s normal. This article outlines some important things to think about when discussing self-injury, as well as providing some tips that might help make the conversation go more smoothly.
When and where to have the conversation
Self-injury is often associated with uncomfortable emotions, like shame and guilt.5 Because of this, it’s important to ask about self-injury in a way that makes the person feel comfortable instead of making the individual feel more ashamed or guilty. Ask about self-injury in private, away from other people. Make sure you have plenty of time, and avoid discussing the topic at a time when one or the other of you is already upset.
How to start the conversation
Before you start asking questions, tell the person that you’ve noticed that he or she is having a hard time, that you care and that you want to help. For example, you might say, “I’ve noticed that you’ve been really down the last few times we’ve met, and I’m concerned. Can we talk about how you’ve been doing?” If the person seems nervous, you might even say, “I know it can be tough to talk about these things, but I think it’s important enough that we should talk anyway, even if it’s awkward.”
What questions you should ask first
It’s important to be clear and direct. Avoid using generic phrases like “hurting yourself,” because these can mean different things to different people. You could start with something like “Sometimes when people are struggling, they do things like cutting or burning themselves, not as a way to die, but to try to feel better or to get help from other people. Have you ever done anything like that?”
Then, if the person is self-injuring, there are lots of different aspects of the self-injury that you may want to ask about. For starters, it’s important to know the severity of the self-injury, and the motivation (or function) of the self-injury.
How to ask about severity
Knowing the severity of someone’s self-injury will help you to help the person stay physically safe. Most self-injury causes minimal physical harm, but some self-injury can cause major health problems or even accidental death. Here are some good questions to ask:
What specific methods of self-injury have you used?
How often have you been self-injuring?
Have you ever needed medical attention for self-injury?
Have you ever thought you needed medical care for self-injury, but didn’t get it?
Have you had thoughts about other kinds of self-injury methods? If so, which ones?
These questions can help you understand whether the self-injury may be medically dangerous. If you’re not sure, you can always refer the person to a physician or the nearest emergency room for more assessment. We know that those who self-injure are more likely to report a suicide attempt.6 Even if the person is not currently in need of medical attention, it is important to know about self-injury severity because people who self-injure are more likely to also experience suicidal thoughts and behaviours, and self-injuring more often or with more methods of self-injury can be related to a greater risk of suicide attempts.
How to ask about motivation
We all have reasons for doing the things we do. This is true for self-injury, too. Even if others can’t understand the person’s reasoning, everyone who self-injures does so because it seems like the best option at the time—even if it causes problems later. Knowing why someone self-injures will help you understand and support the person. Your knowledge may also help mental health professionals provide the best care possible.
People usually self-injure for two types of reasons: they wish to change something within themselves (most common), or they wish to change something about their relationship with another person (less common).7 Most people who self-injure say that self-injury helps them feel less sad, scared or angry immediately afterward, even though they may continue to have those feelings (or worse feelings) later. Many describe self-injury as a way to punish themselves. Less often, people use self-injury as a way to reach out to others for help, or to avoid interacting with other people.8 Here are some good questions to ask:
What usually happens right before you self-injure?
How do you feel before you self-injure? How do you feel right after?
What does self-injury do for you?
What about your self-injury is helpful to you? What isn’t as helpful?
Do you want to stop self-injuring? Why (or why not)?
These questions let the person know that you care, and that you won’t dismiss the self-injury as “attention-seeking” or “irrational.” Knowing what self-injury means to someone is the first step to helping him or her find other coping strategies to use instead.
Where to go from here
Once you’ve talked to someone about self-injury, what’s the next step? Here are a few options to consider:
- Let the person know there’s help available 24/7 if he or she is struggling. In British Columbia, the Crisis Centre offers phone and chat counselling specifically for youth; you can find information about the centre at crisiscentre.bc.ca.
- Develop a safety plan. What can the person do instead of self-injuring? Who can the person call or text? What else could help when he or she is upset? Some ideas for coping with self-injury urges can be found at sioutreach.org.
- Find a school counsellor, physician, therapist, psychologist or another professional who can help. In British Columbia, you can call 811 to get free, non-emergency health information, including information about mental health concerns.
Asking someone about self-injury can feel intimidating and distressing, but it can also be a very important step to getting someone the help they need. By being respectful, genuine and compassionate, you can provide support and resources to someone who might otherwise feel alone and hopeless. For more information about assessing self-injury, see the sidebar panel.
Where can I learn more about self-injury assessment?
Depending on the setting, your training and other factors, you may want to use a more structured method to ask about self-injury in more detail. Here are a few useful assessment tools:
- Inventory of Statements About Self-Injury
This questionnaire asks about self-injury methods and motivations or functions for self-injury. It is very brief and frequently used, although it does not cover some aspects of self-injury, such as medical severity. You can find the questionnaire at www2.psych.ubc.ca/~klonsky/publications/ISASmeasure.pdf.
- Ottawa Self-Injury Inventory
This questionnaire asks about self-injury methods, motivations and characteristics. It is very thorough and includes many items, but it does take longer to complete than others. You can find this questionnaire at www.insync-group.ca/publications/OSI-2015-English-v3.1.pdf.
- Self-Injurious Thoughts and Behaviors Interview
This interview asks about nonsuicidal self-injury and suicidal thoughts and behaviours. It gives the user information about different kinds of self-injury, both suicidal and nonsuicidal, but does require that someone ask questions in an interview format rather than allowing the interviewee to self-report. You can find the interview at projects.iq.harvard.edu/files/nocklab/files/sitbi_longform.doc.
- Nonsuicidal Self-Injury Disorder Scale
This questionnaire is meant to go along with other measures of self-injury methods, to assess whether the person meets diagnostic criteria for Nonsuicidal Self-Injury Disorder in the DSM-5. You can find the questionnaire at www2.psych.ubc.ca/~klonsky/publications/NSSIDS_measure.pdf.
Have more questions about supporting someone around self-injury? Join a Q&A in early November!
Visions contributor experts will be available for a discussion panel on twitter, a tweet chat. The tweet chat will take place on November 9, 11-12 Pacific Time, using #nssichat. Follow them now on Twitter at @HeretoHelpBC.
- 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. doi:10.1186/s12889-015-2383-0.
- Bjärehed, J., Pettersson, K., Wångby-Lundh, M. & Lundh, L.G. (2013). Examining the acceptability, attractiveness, and effects of a school-based validating interview for adolescents who self-injure. The Journal of School Nursing, 29(3), 225-234. doi:10.1177/105984051245852.
- Muehlenkamp, J.J., Swenson, L.P., Batejan, K.L. & Jarvi, S.M. (2015). Emotional and behavioral effects of participating in an online study of nonsuicidal self-injury: An experimental analysis. Clinical Psychological Science, 3(1), 26-37. doi:10.1177/2167702614531579.
- Dazzi, T., Gribble, R., Wessely, S. & Fear, N.T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S003329171400129.
- Victor, S.E. & Klonsky, E.D. (2014a). Daily emotion in non-suicidal self-injury. Journal of Clinical Psychology, 70(4), 364-375. doi:10.1002/jclp.2203.
- Victor, S.E. & Klonsky, E.D. (2014b). Correlates of suicide attempts among self-injurers: A meta-analysis. Clinical Psychology Review, 34(4), 282-297. doi:10.1016/j.cpr.2014.03.00.
- Klonsky, E.D., Glenn, C.R., Styer, D.M., Olino, T.M. & Washburn, J.J. (2015). The functions of nonsuicidal self-injury: Converging evidence for a two-factor structure. Child and Adolescent Psychiatry and Mental Health, 9(44). doi: 10.1186/s13034-015-0073-4.
- Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27(2), 226-239. doi:10.1016/j.cpr.2006.08.002.
Sarah E. Victor, PhD studied clinical psychology at the University of British Columbia and is now a postdoctoral scholar at the University of Pittsburgh School of Medicine. Her research and clinical work focuses on understanding nonsuicidal self-injury, suicidal behaviours and the relationship between the two, particularly in adolescence and young adulthood.