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Section 6
A Compassion-Focused Approach to Nonsuicidal Self-Injury

Question 6 | Test | Table of Contents

Nonsuicidal self-injury (NSSI) has been occurring at alarming rates among youth. In Canada and the United States, prevalence ranges from 12% to 41% in community samples of adolescents and young adults (Gratz & Roemer, 2008; Klonsky, 2007; Laye-Gindhu & Schonert-Reichel, 2005). Similar rates have been reported in the United Kingdom and Australia (De Leo & Heller, 2004; Hawton, Rodham, Evans, & Weatherall, 2002). For youth receiving mental health treatment, NSSI prevalence is considerably higher; some studies sugges that as many as 40% to 60% of adolescents in psychiatric samples self-injure (Klonsky & Muehlenkamp, 2007; Nock & Prinstein, 2004).

The reasons why people self-injure differ from person to person, and multiple motivations may co-exist (Nock & Prinstein, 2005). However, it appears that self-injury is most often motivated by the need to regulate negative affective states, to punish the self, and to influence or communicate with others (Briere & Gil, 1998; Chapman & Dixon-Gordon, 2007; Klonsky & Muehlenkamp, 2007). These motivations must be addressed in working with people who self-injure. In particular, there is a need for counseling approaches that strengthen client emotion regulation, self-acceptance, and positive ways of relating with others.

This article proposes compassion-focused therapy (CFT; Gilbert, 2009, 2010) as one approach for working with adolescents and young adults who self-injure. Recently developed by Paul Gilbert and his colleagues (Gilbert & Irons, 2005; Gilbert & Proctor, 2006), CFT is a form of cognitive behavioral therapy aimed at helping people with mental health problems that are related to shame and self-directed hostility. The main goal of CFT is to change the ways individuals relate to themselves through processes that generate warmth, understanding, nonjudgment, and kindness toward the self.

 In contrast, traditional cognitive behavioral strategies seek to identify and directly challenge faulty cognitions and thus may inadvertently reinforce people’s perceptions of themselves as fundamentally flawed. As a therapeutic approach that attempts to encourage self-soothing behaviors, foster self-acceptance, and help people feel connected to others, CFT may be particularly well suited to address the most common functions associated with self-injury.

We begin by defining NSSI; describe its forms, characteristics, risk factors, and functions; and review current counseling approaches used in the treatment of NSSI. Next, we define compassion and self-compassion and briefly summarize recent studies of the relationship between self-compassion and psychological well being. This is followed by an introduction to the theoretical bases and aims of CFT and discussion of how CFT principles and techniques can be applied to counseling clients who self-injure. Finally, we conclude with considerations for mental health professionals using compassion-focused interventions for NSSI.

Nonsuicidal self-injury

Definition and forms of NSSI
This article defines NSSI as the deliberate destruction of mutilation of one’s own body tissue without the conscious intention to die and excluding socially accepted behaviors (Klonsky & Muehlenkamp, 2007; Nock, Teper, & Hollander, 2007). Some alternative terms for NSSI are deliberate self-harm, self-injury, self-mutilation, and nonsuicidal parasuicide. NSSI is contrasted to suicide attempts or wounds inflicted with suicidal intent.

Among common forms of NSSI are skin cutting, burning, severe scratching, biting, banging, hitting, wound picking, and hair pulling (Klonky, 2007; Ross & Health, 2003; Whitlock, Eckenrode, & Silverman, 2006). In some cases bone breaking, swallowing toxic substances, and self-surgery may over (Wester & Trepal, 2005; Whitlock et all., 2006). Most people who self-injure use multiple methods of self-harm (Klonky & Muehlenkamp, 2007).

Characteristics of NSSI
NSSI is associated with a range of other mental health problems, including depression, anxiety, substance abuse, borderline personality disorder, eating disorders, suicidality and posttraumatic stress reactions (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006; Zlotnick, Mattia, & Zimmerman, 1999). Although by definition NSSI is not suicidal in intent, self-injurers are at an increased risk of serious physical injury or death (Whitlock et al., 2006). NSSI may also lead to increased shame, guilt, and social isolation (Gratz, 2006). While the average age of onset of NSSI is between 12 and 16 years old (Heath, Toste, Nedecheva, & Charlesboid, 2008; Nock et al., 2007), self-injury has been reported in children as young as 6 (Nock&Prinstein, 2004).

Between 63% and 75% of self-injurers engage in self-injurious behaviors more than once, and 17% to 25% self-injure more than 10 times (Borrill, Fox, Flynn, & Roger, 2009; Gratz, 2006; Whitlock et al., 2006). Some studies of clinical samples have found higher rates of self-injury among clinical samples of females than males (Laye-Gindu & Schonert-Reichl, 2005; Nixon, Cloutier, & Jansson, 2008). However other studies have found no gender differences in either clinical and community samples (Briere & Gil, 1998; Whitlock et al., 2006).

NSSI occurs across cultures and ethinicities, though there is some indication that rates are higher among Caucasian adolescents and young adults than among non-Caucasian youth (Gratz, 2006; Ross & Heath, 2003; Whitlock et al., 2006). However, some studies have found no ethnic differences in the incidence of self-injury (Corrill et al., 2009; Hilt, Cha, & Nolen-Hoeksema. 2008).

Risk Factors
Difficulties with emotional regulation and distress tolerance are common in cases of NSSI. People who self-injure often struggle with recognizing and expressing their emotions (Gratz&Roemer, 2008; Horne & Csipke, 2009; Sim, Adrian, Zeman, Cassana, & Friedrich, 2009). Studies of NSSI have reported higher levels of negative emotions and subjective emotional distress and increased physiological reactivity to stress (Klonsky & Muehlenkamp, 2007; Nock & Mendes, 2008). NSSI may also be related to having a limited repertoire of healthy strategies to cope with intense emotional arousal (Gratz & Roemer, 2008; Heath et al., 2008). Individuals who self-injure may employ fewer problem-solving strategies and more avoidance behaviors than those without a history of NSSI (Brown, Williams, & Collins, 2007; Chapman, Gratz & Brown, 2006).

High levels of self-criticism and negative self-concept have also been observed in people who self-injure (Adams, Rodham, & Gavin, 2005; Chapman & Dixon-Gordon, 2007; Glassman, Weierich, Hooley, Deliberto, & Nock, 2007). NSSI appears to be associated with self-hatred, self-doubt, feelings of worthlessness, and sense of inadequacy (Adams et al., 2005; Sim et al., 2009). Childhood abuse, including sexual, physical, and emotional abuse or neglect may further place individuals at risk for NSSI (Briere & Gil, 1998; Gratz, 2003). However, many people who self-injure have no history of being maltreated, and research on childhood physical abuse and neglect is inconclusive (Briere & Gil, 1998; Heath et al., 2008).

Main Functions of NSSI
There is considerable evidence that emotion regulation may be the primary function of NSSI (Briere & Gil, 1998; Chapman et al., 2006; Gratz, 2003; Klonsky, 2007). It may serve as a means of self-soothing or avoiding unwanted feelings in response to emotional distress. In numerous studies adolescents and adults who self-injure have reported intense negative affect before self-harm, followed by temporary feelings of calmness and comfort afterwards (Briere & Gil, 1998; Chapman & Dixon-Gordon, 2007; Harris, 2000; Klonsky & Muehlenkamp, 2007).

 It has also been suggested that NSSI may trigger the release of endorphins (Nock & Mendes, 2008), which have been hypothesized to be related to self-soothing brain functions (Gilbert, 2010)., Temporary feelings of comfort and tension reduction may thus reinforce self-harming behaviors (Briere & Gil, 1998; Gratz, 2007).

The likelihood of self-injury may be exacerbated by the feelings of shame and isolation that often result from NSSI (Gratz, 2006). Thus, the individual may be trapped in a painful cycle of negative emotional arousal and self-injury. For some people who self-injure, NSSI may also be motivated by the desire to feel more alive in response to emotional numbness or to disrupt states of dissociation or de-realization (Briere & Gil, 1998; Klonsky & Muehlenkamp, 2007).

Another major function of NSSI is self-punshisment or the expression of self-contempt (Chapman & Dixon-Gordon, 2007; Klonky & Muehlenkamp, 2007; Laye-Gindhu & Schonert-Reichl, 2005). NSSI may be an attempt to cope with shame by punishing the self for perceived defects or "cutting out the bad" inside oneself (Harris, 2000). It has also been suggested that the self-punishment function may be a way of pre-empting punishment from other people, thereby maximizing a sense of control (Chapman et al., 2006). This echoes psychoevolutionary perspectives that see self-criticism as a possible form of submission aimed at averting attack from dominant, hostile people (Gilbert, 2009; Gilbert & Irons, 2005).

Although less common than the functions mentioned, self-injury is also often motivated by the desire for interpersonal influence or communication (Klonsky & Muehlenkamp, 2007). For example, self-harm may be used to communicate distress, elicit caring or attention from others, or, in the minority of cases, manipulate people into having in ways that they would not otherwise do (Horne & Csipke, 2009; Nocke & Prinstein, 2005). Among adolescents, self-harm may also provide a way for people to bond with friends who self-harm (Klonsky & Muehlenkamp, 2007).

- Van Vliet, K Jessica;Kalnins, Genevieve R C. A Compassion-Focused Approach to Nonsuicidal Self-Injury. Journal of Mental Health Counseling; Oct 2011; 33, 4; ProQuest pg. 295

Personal Reflection Exercise #6
The preceding section contained information about the compassion aprroach when it comes to non-suicidal self-injury. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Adrian, M., Berk, M. S., Korslund, K., Whitlock, K., McCauley, E., & Linehan, M. (2018). Parental validation and invalidation predict adolescent self-harm. Professional Psychology: Research and Practice, 49(4), 274–281.

Carneiro, R. (2020). Tigress in a cage. Families, Systems, & Health, 38(2), 218.

Nilsson, M., Hellström, C., Albin, V., Westrin, Å., Lundh, L.-G., & Westling, S. (2020). Measuring tolerance toward self-harm: Introducing the Lund Tolerance Toward Self-Harm Scale (LUTOSH). Stigma and Health, 5(3), 315–322.

What is the main goal of Compassion-Focused Therapy when used with SIB?
To select and enter your answer go to Test.

Excerpt of Bibliography referenced in this article

Section 7
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