Non-suicidal self-injury (NSSI) is the deliberate and direct destruction of one’s body tissue, without suicidal intent and for reasons not socially or culturally sanctioned. This definition excludes tattooing, piercing, and indirect harm such as substance abuse or eating disorders.

NSSI should also be distinguished from self-injurious behavior (SIB) that is commonly seen among individuals with intellectual and developmental disabilities.

The most common methods of self-injury include cutting, burning, scratching, and bruising. These injuries can range in severity from minor to moderate. Self-injury can start at any age, but most people who self-injure start when they are teenagers. Many people who start self-injuring in their teens continue into adulthood, while others may start self-injuring as adults. Although any one at any age may begin to engage in self-injury, research shows that the most common age of onset for self-injury is early adolescence, more than half of young adults who have engaged in self-injury recall starting at this time, however slightly less than a quarter recall starting before age 12.

Prevalence

Although any one at any age may begin to engage in NSSI, the most common age of onset for NSSI is early adolescence. Between 14 and 20% of adolescents in community samples report having engaged in NSSI at least once in their lifetime. This rate may range from 60 to 80% in clinical samples. Recent research indicates that there is little to no sex difference in prevalence of NSSI in community samples. However, in clinical samples, NSSI is more prevalent in females.

Individuals who engage in NSSI may injure themselves repetitively over long periods of time, with increasing severity, and may use different methods over time. Alternatively, they may reduce their NSSI behavior before beginning again during periods of high stress.

14-24% of youth or young adults have self-injured at least once. One quarter of those have done it many times.

There are many reasons why students self-injure. In fact, students often give more than one reason for their NSSI and some students’ reasons may change over time. Research has shown that the most common reason for NSSI is to cope with difficult feelings (e.g., distress, anxiety, stress, sadness, numbness). Students might injure themselves because they feel overwhelming negative emotions from which they feel they are otherwise unable to find relief.

Other reasons have been given for NSSI. These can include (but are not limited to): communicating feelings, avoiding acting on thoughts or urges related to suicide, self-punishment, or ending a feeling of emotional numbness.

It can be difficult to identify a student who is engaging in NSSI. For many teens, self-injury is a secretive behavior and it can be difficult and uncomfortable to talk about it with others. When students do share their experiences of NSSI, they tend to be more likely to tell a friend than an adult.

Here are a few possible signs of self-injury that are important to be aware of:

1. Unexplained cuts, burns or bruises; these typically occur on the arms, legs and stomach.

2. Possession of razors, shards of glass, knives, thumb tacks, or other items that teens may use to self-injure (keep in mind that any sharp object may be used to injure; e.g., paper clips, ends of pencils).

3. Continually wearing clothing that is inappropriate for the weather or the situation (e.g., bulky, long-sleeved clothing in hot weather or gym class).

4. Noticing evidence of, or references to, self-injury in a student’s creative writing, journals, or art projects.

It is important to note that if you see these signs in a student, it does not necessarily mean that he or she is engaging in NSSI.

It is important for teachers, administrators, and school mental health professionals to be educated about the high rate of occurrence of self-injury in teens, the methods teens use to injure themselves, and the reasons why they engage in NSSI.

Once it is known that a student is engaging in NSSI or when a student discloses these behaviors your initial response is very important; it will likely influence the student’s willingness to seek help in the future. You may feel uncomfortable with the idea of talking with a student about NSSI. Some people feel shocked, or even horrified by NSSI; these are normal reactions to have. Keep in mind, though, that you may be the first person that a student talks to about NSSI; the student is likely to be scared and nervous. By being prepared, you can monitor your own reaction to help the student feel more comfortable, and to increase the likelihood of them seeking further help.

The following DOs and DON’Ts will help you be prepared to help any student who may be injuring.

DO

1. Communicate with the student in a calm, and caring way.

2. Let the student know that there are people who care about him/her and that he/she is not alone and that other youth self-injure.

3. Understand that this is a way for the student to cope with the pain that he/she is feeling.

4. Use the student’s language for self-injury when talking about self-injury (e.g., if a student calls it ‘cutting’ or ‘self-harm’ use that term in your discussion).

5. Listen to the student, in order to better understand his/her behavior.

6. Use non-judgmental language and demeanour.

DON’T

1. Be overly reactive; this could alienate the student.

2. Respond with panic, revulsion, shock, or averted gaze.

3. Try to stop the self-injury behavior with threats or ultimatums.

4. Show excessive interest in the details of the student’s self-injury (e.g., what exactly was done).

5. Permit the student to relive or describe the experience of self-injury in detail as this may trigger the desire to engage in self-injury again.

6. Talk about the student’s behavior in front of the class or around peers.

7. Engage in unmonitored discussions about self-injury with your class.

8. Tell the student that you won’t tell anyone about their self-injury. (You may be required to break confidentiality based on school protocol – please see below).

It is essential for school personnel to monitor themselves to ensure they respond in a calm, respectful, and helpful way if a student discloses NSSI. This may be the student’s only disclosure about his/her self-injury, and therefore, an important one.

Following the initial response to identification or the disclosure of NSSI, the student should meet with the school’s mental health professional (e.g., counselor, school psychologist, nurse, social worker, guidance counsellor) so that an initial risk assessment can be conducted.

Additional information regarding this assessment can be found on the mental health practitioner fact sheet available on here.

The referral process can be difficult for both students and school personnel. A student may have approached you in confidence as someone who he or she trusts and may be resistant to sharing his/her NSSI with others. Let the student know that you care about him or her, and are concerned about his/her welfare, and that you want to help him/her get support.

Accompany the student to the school’s mental health professional. If the student would like, stay with him or her during this meeting. It may be easier for some students if you relate the NSSI to the mental health professional in the student’s presence; this helps to set the tone of the dialogue, and allows a hesitant student the opportunity to enter more gradually into this process. Offer this option if the student is not ready to speak on his or her own behalf, but make sure that you check in with the student during the meeting to ensure that you are getting his/her story right and to see if he/she would like to add or clarify details.

To facilitate a smooth transition from the time of identification to referral and ongoing support, your school should have a protocol in place that outlines a standard response. A response protocol documents the school’s procedures for dealing with incidents or reports of NSSI; it should be developed and agreed upon by all school personnel.

Key issues to be addressed in the protocol:

1. When school personnel should report a student suspected of self-injuring, and to whom this should be reported (all school personnel should know who the designated mental health professional is as well as who the replacement is in the event of an absence).

2. Identification of the roles of each member of the school personnel team

3. Policies to guide the initial risk assessment

4. When a student should be referred to outside services

5. A policy regarding parental notification and contact

It is very important to recognize that NSSI and suicide are distinct. Engagement in NSSI does not necessarily mean that a student is suicidal. In fact, many youth who engage in NSSI appear to be functioning very well socially and academically. Nevertheless, every student who is identified as engaging in NSSI should be assessed for suicide risk in the initial risk assessment that is completed by the school’s mental health professional (click here to link to our mental health professional information page). If there is any associated suicide risk, the student should be referred to emergency mental health services.

A main concern in schools is a student’s decision to no longer conceal injuries or scars from self-injury. This is perceived as a concern due to the possibility of upsetting other students or serving as a suggestion to other students. However, research suggests that there may be differences between how other youth view injuries apart from scars. Specifically, while some students who self-injure may view injuries and find these upsetting, this may not be the case for scars. In fact, there is evidence indicating that coming to accept one’s scars and making the choice to no longer conceal them can be very beneficial to a student’s recovery.

Therefore, when responding to students who have recent injuries and are still actively struggling with their self-injury, we recommend:

1. Asking the student to cover recent injuries, as they may pose a standard health concern within the school as well as being more likely to upset fellow students which should be explained to students.

2. Having a conversation with the student in which their desire to not conceal recent injuries is validated while explaining to them that there is some evidence that the viewing of wounds by those who may be still struggling with their recovery could contribute to potential relapse.

In contrast, when students choose to no longer hide their scars, this may represent a positive step in their recovery as it may indicate diminished shame for having self-injured. Therefore, we advise supporting students in this difficult decision with an empathic and supportive discussion with attention to the following:

1. Recognize that for some students, it can be counterproductive to keep their scars hidden

2. Acknowledge that this is the student’s choice and that this may be a positive step for them

3. Discuss with the student how they will handle possible intrusive questions, negative comments

4. Develop a clear plan for how the student can alert the appropriate school personnel should any bullying occur. Ensure that the specified person is aware of the plan.

5. Ensure that regular check-ins with the student are scheduled to monitor the situation and provide ongoing support

A concern in the school environment is the possibility of contagion or the spread of NSSI. Contagion refers to the sequence of events in which an individual engages in NSSI and is imitated by others. Most commonly the spread of NSSI occurs through communication between peers about the behavior.

When discussing NSSI with students, the following guidelines will help in preventing contagion:

1. Do not allow students to share detailed information regarding NSSI, or share NSSI related images or stories.

2. Do not use school-wide assemblies, newsletters, school newspapers to address an “outbreak” of NSSI.

3. When educating youth about NSSI, discuss the behavior in its broader context; that is, as an unhealthy coping strategy among several others (such as substance abuse, or risk-taking).

4. Emphasize the need for students who are engaging in the behavior to seek support.

Parent contact remains a debated topic among school personnel. When and how to contact parents regarding a student’s NSSI should be clearly outlined in a school’s response protocol and should be in line with provincial or state laws.

In the event that the school’s mental health professional must contact parents, this should always be done with the involvement of the student. Some students may be too nervous or scared to disclose their NSSI to their parents. By taking this step together, as a supportive team, some of this fear and anxiety may be reduced.

Self-injury is not a life-sentence. Students CAN and DO STOP self-injuring. However, the longer the student self-injures, the more difficult it can be to stop. It is important to remember that stopping a behavior that has become a frequently used unhealthy coping strategy will take time, effort and new healthy coping strategies. Stopping self-injury is not something that occurs over night, or with threats (e.g., you cannot come to school until you stop). In fact, this approach may increase negative emotions for the student and may increase self-injury.

Many students who self-injure do it in private and work very hard to keep it a secret. In these cases, the self-injury may sometimes be accidentally discovered (e.g., in gym class). Some students who self-injure will tell one or two close friends or family members; they may also tell others who self-injure online. Other students who self-injure will talk to a professional (like a counsellor, psychologist or a doctor) about their self-injury.

It is important that students who self-injure be provided with helpful resources and, if they are open to it, professionals who can support them in their efforts to cope better. Mental health professionals (such as counsellors, social workers, psychologists and psychiatrists) are trained to help people learn healthier ways to cope, and can be helpful in supporting students who self-injure.

This website has very current best practice information and resources that can be shared with the professional (click here to link to our mental health professional information page). Some students who self-injure are not ready and/or willing to seek professional help. It is possible to learn healthier ways to cope without a professional but it may be extremely difficult. Resources on this website for students who self-injure can help in efforts to recover (see Coping and Recovery).  

Students who self-injure cannot be forced to stop. Sometimes students who self-injure do not want to stop self-injuring. Remember that self-injury serves a purpose and stopping can be difficult. When students who self-injure start learning healthy ways to cope, then they find stopping self-injury easier.

In closing, school personnel are already dealing with many issues around academic concerns and behavioral challenges. Sometimes schools do not feel that they should play a role in managing self-injury in youth. However, schools are essential in initiating recovery through effective referral. Effective referrals cannot happen without awareness and involvement of school personnel. Remember to consider that school staff see youth frequently. This may be the only time an adult notices the self-injury. This is therefore a crucial point at which intervention can begin.

Books

Gratz, K.L., & Chapman, A.L. (2009). Freedom from self-harm: Overcoming self-injury with skills from DBT and other treatments. Oakland: New Harbringer.

Articles

Heath, N. L., Toste, J. R., Sornberger, M. J., & Wagner, C. (2011). Teacher’s perceptions of non-suicidal self-injury in the schools. School Mental Health, 3, 35-43.

Lewis, S. P., Heath, N. L., St Denis., J. M., & Noble, R. (2011). The scope of non-suicidal self-injury on YouTube. Pediatrics, 127, e552-557.

Toste, J. R. & Heath, N. L. (2010). School response to non-suicidal self-injury. The Prevention Researcher, 17, 14-17.

White Kress, V. E., Gibson, D. M., & Reynolds, C. A. (2004). Adolescents who self-injure: Implications and strategies for school counselors. Professional School Counselling, 7, 195-201.