Nonsuicidal Self-Injury

Advances in Research and Practice

Jason J. Washburn

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351673372
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Nonsuicidal Self-Injury moves beyond the basics to tackle the clinical and conceptual complexity of NSSI, with an emphasis on recent advances in both science and practice. Directed towards clinicians, researchers, and others wishing to advance their understanding of NSSI, this volume reviews and synthesizes recent empirical findings that clarify NSSI as a theoretical and clinical condition, as well as the latest efforts to assess, treat, and prevent NSSI. With expertly written chapters by leaders in the field, this is an essential guide to a disorder about which much is still to be known.

Section III

Assessment and Treatment

Chapter 8

Comprehensive Assessment of Nonsuicidal Self-Injury

Gregory J. Lengel and Denise Styer

Introduction

The assessment of nonsuicidal self-injury (NSSI) can be complex and challenging. NSSI assessment requires careful examination of several variables, the use of multiple methods, attention to an individual’s demeanor, the development of rapport, as well as the identification and prioritization of goals that often vary depending on the context of the assessment. Further adding to the challenge of clinical assessment of NSSI is that the time available for evaluation and clinical decision-making is often limited in real-world clinical contexts. Additionally, assessment does not stop after the initial screening; ongoing assessment of NSSI is necessary over the course of treatment due to the mutability of NSSI urges and behaviors over time.

This chapter reviews the elements involved in a comprehensive clinical assessment of NSSI. While we will discuss many established NSSI assessment tools and strategies below, it is important to emphasize that no single measure, interview, or assessment framework is sufficient for the clinical assessment of NSSI. Therefore, rather than provide details of specific assessment measures, we instead review the critical variables and constructs essential to a comprehensive NSSI assessment.

Initial Screening

Given the association of NSSI with other mental disorders, especially suicide, screening for NSSI should be a routine component of all clinical assessments, regardless of presenting concerns. During the initial intake assessment, clinical assessors should identify if the client has current and past urges to harm his or her self, as well as whether he or she previously engaged, or is presently engaging, in NSSI. When screening for NSSI specifically, it is necessary to differentiate between NSSI and other forms of direct self-harm (e.g., suicidal behavior, indirect self-harm) by determining if the self-injurious behaviors meet the definition of NSSI, that is the “direct, deliberate destruction of one’s own body tissue in the absence of suicidal intent” (Nock & Favazza, 2009, p. 9). Differentiating NSSI from self-harming behavior can be accomplished by simply and directly asking the client questions such as, “Have you ever purposely caused physical harm to yourself without the intention of ending your life?” and “Have you ever purposely attempted to end your life?” during an intake interview, or through the administration of NSSI-specific self-report measures. Once NSSI behavior has been identified, we recommend that an accurate and thorough assessment of the self-injurious thoughts and behaviors be conducted.

History and Severity

A comprehensive examination of the client’s NSSI history is a recommended starting point for clinical assessment of NSSI. A thorough history will include information concerning the onset of the behavior, such as the date of initial injury, date of most recent NSSI episode, the frequency, methods, and tools utilized during each period of NSSI, as well as factors that may have led to the onset of NSSI and the context in which the NSSI occurred (e.g., location, specific prompting events, emotions). We discuss each of these components in greater detail below.

Assessors should collect specifics concerning the course of NSSI behaviors over time. For example, has the individual’s NSSI taken a chronic course with frequent and repeated instances over several years, or a more acute, infrequent course with limited occurrences over recent weeks or months? Has the self-injury been fairly stable across time, or has it fluctuated in frequency, severity, and method since its onset? The assessor should also determine whether the NSSI occurs on a regular basis, or if NSSI occurs more sporadically in response to specific life events and stressors, as well as the factors associated with the stability or instability of the behavior. Further, it is important to identify the client’s typical NSSI behavioral pattern (e.g., method, frequency, duration, severity), as well as the most severe lifetime episode.

Understanding the details of the client’s urges to self-injure is also essential. When did the client begin having urges? How often do urges occur? What prompts urges? How intense are the urges? What contexts prompt more/less, stronger/weaker urges? Further, an assessor must consider how much time typically occurs between urge and action (e.g., seconds, minutes, hours), as well as the degree to which the client is able to delay or resist urges.

The client’s treatment history also informs case conceptualization and treatment planning. If the client has a past treatment history for NSSI, assessors should inquire about the types of intervention received, what was helpful/unhelpful about each intervention, and who provided each intervention. Family history also provides clinically relevant biopsychosocial information. Thus, the assessor should inquire about current or past NSSI (and other mental health concerns) that occurred in the nuclear and extended family. Collectively, this historical information helps assessing risk, severity, and safety, as well as treatment planning.

Determining Severity of NSSI

It is important to determine the severity of the client’s NSSI behaviors. Although all NSSI is potentially cause for concern, not all NSSI is equally severe. Therefore, determining severity is critical in understanding risk and the appropriate level of intervention necessary for the individual. Determining severity of NSSI involves an assessment of frequency, method, damage to tissue, location of the wound, and tolerance of the injury.

Frequency

Frequency of urges and behaviors can vary greatly from person to person as well as within an individual over the course of one’s life. Cases involving more frequent self-injury are higher risk and more severe. More frequent NSSI increases risk for several physical and mental health consequences, including death. While there are no formal standards in determining severity by frequency, Whitlock and colleagues (2008) provide helpful cut-offs. Individuals who reported less than 11 lifetime NSSI incidents and who tended to use only one, low tissue damage NSSI method were categorized as “superficial self-injurers.” Those with a limited number of lifetime NSSI instances (i.e., less than 11), but who used three or fewer methods, with at least one that leads to moderate to high level of tissue damage, were classified as “moderate severity self-injurers.” Finally, those who reported moderate to high-frequency lifetime NSSI incidents and more than three methods, with at least one dangerous method that leads to a high degree of tissue damage, were classified as “high severity self-injurers.”

Method

As noted by Whitlock and colleagues (2008), it is not enough to just understand the frequency of NSSI, but also the number of different NSSI methods an individual has used over their lifetime. There are an infinite number of NSSI methods. While skin-cutting is the most commonly reported method (Klonsky, 2007), other common methods include burning, scratching, skin-puncturing, hitting oneself, and ingesting poisonous substances. Notably, many individuals utilize multiple NSSI methods (Nock & Favazza, 2009). When inquiring about methods used, we recommend asking open-ended questions in addition to asking about specific methods (e.g., “In what other ways have you deliberately harmed yourself without the intent of ending your life?”), as this allows one to potentially detect unconventional methods of NSSI.

Some methods (e.g., skin-cutting with razors, burning) can lead to substantial tissue damage and increased risk of severe injury or death compared to others (e.g., scratching with fingernails). Further, the number of NSSI methods utilized is indicative of risk, as research suggests that a greater number of NSSI methods is predictive of suicide behavior (Victor & Klonsky, 2014). Thus, the use of multiple methods should signal heightened clinical concern.

Similarly, the tools utilized to injure can also indicate severity. Are specific tools used to injure, or does the client injure with whatever is available? Does the client have access to and capability of using these tools? For individuals who injure with whatever tools are available (e.g., sharp objects, corners of tables, hot objects to burn skin), careful consideration should be made to identify ways of keeping the client safe. Additionally, it is significant to assess the location that the individual stores their tools (e.g., kept on person, hidden in a room), as well as whether the individual uses specific tools only (e.g., razor blade, knife, pin), or if they are inclined to use whatever they can find to harm themselves (e.g., sharp corner of a desk, pencil).

It is important to note that methods, in and of themselves, are not a sufficient means of determining severity because there is great variability in tissue damage within and across methods. For example, skin-cutting can range from superficial scratches that immediately scab over to deep wounds that require urgent medical intervention. Therefore, a determination must be made regarding how and to what degree the individual utilizes a particular method. Another variable to consider when evaluating the severity of the behavior is if and how one’s NSSI methods have changed since initial onset. A gradual escalation in the severity of the method utilized could be indicative of higher risk, particularly a growing tolerance for pain or a decreasing reinforcement from the behavior. For instance, an escalation from superficially scratching oneself with a fingernail to deeply cutting oneself with a razor can be indicative of a worsening course.

Tissue Damage

The amount and degree of tissue damage is perhaps more significant than the specific methods utilized. NSSI can lead to significant or permanent tissue damage, require first aid, or could potentially place the individual at risk of accidental death (e.g., cutting near major arteries). Accordingly, it is critical to determine the extent to which tissue damage has occurred. Is the injury localized to a single area of the body, or to several areas? How many cuts, burns, etc. are present? How medically severe are the injuries? Although assessors with mental health training can assess the severity of damage from NSSI, it is preferable that a trained medical provider, such as a physician or nurse, perform this assessment.

The stages of wound healing and scars can provide insight to the chronicity, severity, and course of NSSI behavior. Wounds that are in various stages of healing, reopened and persistent wounds, and appearance of scars point towards significant, ongoing, self-injurious behavior. A lack of scars could indicate that the NSSI onset is more recent, while a lack of “fresh” wounds and bruises could indicate a lessening in frequency.

The client’s need for medical treatment (e.g., emergency room visit, sutures, burn wrap) at any point as a result of self-injurious behavior is also indicative of severity of tissue damage. Similarly, it is important to determine whether the individual ever caused more damage or harm than initially intended, as one might inadvertently cause severe tissue damage or even death, despite not intending to do so. Engaging in NSSI that required medical attention or was more severe than initially intended is a cause for heightened concern.

Wound Location

Individuals may injure in a variety of locations on the body. Often, NSSI is clustered on a certain part of the body (e.g., forearms, upper arms, thighs). Wounds located in places where accidental injury is uncommon or atypical, such as one’s stomach, thighs, and chest can be a sign of NSSI. It is common to see several wounds of a similar size, in a similar direction, or in a particular pattern or shape, located close together on the body (e.g., line of several small cuts along the forearm).

A client might injure in a particular location for a variety of reasons. For example, NSSI in a location that is very visible (e.g., wrists, while wearing short sleeves) might indicate a desire to communicate their NSSI, while injuries on the upper extremities or other areas regularly covered by clothing might indicate a desire to conceal NSSI behavior. Others may injure in particular locations or patterns for symbolic reasons (e.g., cutting breasts or genitals following sexual abuse to punish oneself). As part of an ongoing assessment, the assessor should note whether the individual changes the location of NSSI. A location change might be done for practical reasons, such as shifting from injuring on forearms or thigh...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• List of Figures and Tables
• Author Biographies
• Preface
• Acknowledgments
• List of Abbreviations
• Section I Introduction to Nonsuicidal Self-Injury
• Section II Emerging Conceptual and Categorical Issues
• Section III Assessment and Treatment
• Index