Healing Together

Abstract

Nonsuicidal self-injury (NSSI) has become increasingly common among teens and emerging adults. An individual may engage in NSSI for a variety of reasons from coping with emotional pain or as a distraction from difficult thoughts and painful memories. Although NSSI is a common presenting concern, those in supportive roles of clients struggle to understand the motivations to self-injure as well as how to include appropriate supportive family members in the counseling process for long-term healing. The purpose of this article is to (a) review attachment styles in conceptualizing NSSI, (b) discuss the value of including supportive caregivers/family members in treatment, and (c) provide an evidence-based summative list of suggestions for counselors to provide to caregivers. A case illustration is provided.

Keywords

attachment nonsuicidal self-injury adolescent emerging adult family therapy

One in five undergraduate college students is estimated to engage in some form of nonsuicidal self-injury (NSSI; Dellinger-Ness & Handler, 2007). With high estimates of NSSI in teens and young adults, counselors must be knowledgeable of NSSI to appropriately work with clients and their caregivers (Dellinger-Ness & Handler, 2007; Gollust, Eisenberg, & Golbertstein, 2008; Tuisku et al., 2013; Whitlock, Eells, Cummings, & Purington, 2009). NSSI is defined as the deliberate destruction of body tissue without conscious suicidal intent (Aizenman, 2009; Buser & Buser, 2013; Favazza, 1998; Rossouw & Fonagy, 2012). Clients typically demonstrate NSSI through behaviors such as cutting or burning skin, head banging, skin picking, and interfering with wound healing, with cutting and burning being the most frequently reported (Wester & Trepal, 2005). NSSI is often erroneously categorized as a suicide attempt by counselors and caregivers, which can cause caregivers to be overwhelmed with their own emotional reactions while attempting to help the client (Trepal, Wester, & MacDonald, 2006; Yip, 2005). Society tends to misunderstand and stigmatize self-injurious behaviors, labeling those who engage in NSSI as attention-seeking and manipulative (Hoffman, Hinkle, & Kress, 2010). Regardless of the stigma, NSSI continues to increase in prevalence and severity. Rossouw and Fonagy (2012) found that 17% of participants in a U.S.-population-based survey engage in self-harm behaviors, and of those who self-harm in adolescence, 30% continue these behaviors into adulthood. Given the misunderstandings and the high prevalence of NSSI, it is crucial for counselors to understand NSSI as well as approaches to treatment.

It is evident that NSSI can be an agonizing symptom in a family system. Although each family is uniquely different and in need of thoughtful individualized treatment, several themes are consistent that could provide insight for family members to support a loved one struggling with NSSI (Trepal et al., 2006). A common and understandable lack of knowledge and awareness from family members regarding NSSI can be emotionally hurtful to self-injuring clients as well as their family members who may be struggling to know how to help. From our experience and a synthesis of the relevant literature, an attachment-based family systems approach combined with psychoeducation is an effective and appropriate approach. Because NSSI is often labeled as borderline personality disorder (BPD), dialectical behavioral therapy has been the primary treatment approach (Davidson & Ireland, 2009; Trepal & Wester, 2006). While NSSI is traditionally linked to BPD, not all clients who demonstrate NSSI have BPD. Therefore, conceptualizing NSSI only as a symptom of BPD limits treatment options for clients who may not meet criteria for BPD and calls to the need for professional counselors to conceptualize NSSI through a much more comprehensive framework for best practice. The approach we are presenting provides a needed strength-based perspective for the treatment of NSSI. The purpose of this article is to (a) review attachment styles in conceptualizing NSSI, (b) discuss the value of including family members in treatment, and (c) provide an evidence-based summative list of suggestions for caregivers. A case illustration is also provided.

NSSI From an Attachment Perspective

NSSI has been found to be prevalent among adolescents and young adults, which is also when these self-injuring behaviors usually begin (Gollust et al., 2008; Wester & Trepal, 2005). It is widely understood in the literature that those who engage in NSSI are not expressing suicidal gestures, as their self-injuring behavior is with a goal of feeling better and coping with life, not exiting life altogether (Trepal & Wester, 2006; Wester & Trepal, 2005; Wichstrom, 2009). Researchers have also linked NSSI to depression, anxiety, substance abuse, eating disorders, hostility, anger, sadness, and depersonalization (Cheng, Mallinckrodt, Soet, & Sevig, 2010). Furthermore, individuals who lack impulse control are also likely to self-injure (Davidson & Ireland, 2009).

One approach to conceptualizing NSSI is to focus on attachment styles. Insecure attachment styles have been shown to be a correlating risk factor among those who self-injure, indicating that by working toward increasing attachment security, counselors could help reduce NSSI (Hallab & Covic, 2010; Schade, 2013). Through including supportive caregivers in therapy, counselors are more likely to create opportunities to increase attachment security with clients (Schade, 2013). When teens and emerging adults seek counseling for NSSI, whether it be in outpatient or inpatient settings, it is common to expect parents/guardians to be involved in treatment, especially if the client is a minor (Trepal et al., 2006). Therefore, counselors who employ a family therapy approach would have significant success with adolescent and young adults engaging in NSSI.

Overview of Attachment Theory

Bowlby (1969) suggested that humans have an innate need to attach to others in a secure manner and experience belonging. According to Bowlby’s (1969) attachment theory, individuals form attachment styles at birth through the relationship they have with their caregivers. This caregiver–child relationship informs how one relates to others and to the world through their emotional experiences and behaviors throughout life. Ainsworth and Bell (1970) refined attachment theory to include three attachment styles: (a) secure attachment, (b) anxious–avoidant attachment, and (c) anxious–ambivalent attachment. A secure attachment style is formed when a child or individual believes that he or she is inherently a good, lovable person capable of functioning well in the world. Secure individuals can trust that other people are good and will be supportive of them. Therefore, a securely attached person can trust that it is OK to ask others for needs to be met or to be close without much fear of rejection. An anxious–avoidant attachment style is a type of insecure attachment in which the individual does not feel a sense of security that others will be present or supportive. This attachment style usually contributes to difficulties with intimacy in adulthood and causes feelings of discomfort and threat in which the person tends to move away from others all together. An anxious–ambivalent attachment style is another type of insecure attachment in which the individual feels uncertain in relationships. Individuals who have an anxious–ambivalent attachment style feel the need of being very close with a partner, which is not satisfied. This need is connected with a belief that one is inherently undesirable to others and can be marked by a push–pull relationship of seeking closeness with others and simultaneously pushing them away. Attachment theory aims at helping individuals securely attach to appropriate people, easing anxiety with being able to be alone or relating with others without distress (Ainsworth & Bell, 1970; Bowlby, 1969).

Effects of Attachment Style on NSSI

Clients who engage in NSSI tend to have less secure attachment with parents and caregivers than those who do not self-injure (Hallab & Covic, 2010). This is consistent with previous literature that has established that early attachment relationships have important implications for mental health later in life, with insecure attachment linked to difficulty regulating emotion and risky behavior such as NSSI. In addition, insecure attachment style is correlated with higher levels of depression, anxiety, and stress (Hallab & Covic, 2010; Sawicka, Osuchowska, Kosznik, & Meder, 2009; Wichstrom, 2009). Tikka, Ram, Dubey, and Tikka (2014) found that because social influence processes play an important role in the etiology and maintenance of problematic alcohol use, those with an insecure attachment style are more likely to misuse alcohol and other substances. Much literature exists documenting similar findings and adding that insecure attachment style is also linked with psychological distress, eating disorders, and poor self-esteem, which are all contributing factors to NSSI (Davidson & Ireland, 2009; Johnson, Maddeaux, & Blouin, 1998; Kassel, Wardle, & Roberts, 2006; Sawicka et al., 2009). Kassel, Wardle, and Roberts (2006) suggest that those with insecure attachments may lack the necessary skills to form healthy social relationships, and social interactions may cause distress or anxiety. In addition, individuals with insecure attachments may be less likely to be involved in supportive, responsive partner relationships and may resort to NSSI during times of stress or grief. Therefore, due to the correlation of NSSI with insecure attachment styles (Hallab & Covic, 2010; Schade, 2013; Tikka, Ram, Dubey, & Tikka, 2014; Wichstrom, 2009), it seems appropriate to address methods of increasing attachment security when treating NSSI.

It is widely understood that treatment of NSSI is difficult, mainly because people self-injure for a wide array of reasons and in a wide variety of manners (Trepal & Wester, 2006). According to Craigen and Foster (2009), the most important factor in treating NSSI is the therapeutic bond between the client and counselor. What may eventually be shown as an equally important factor in treating NSSI is the healing bond between the client and appropriate supportive family members. Rossouw and Fonagy (2012) conducted a randomized clinical trial and found that of the participants engaged in a family therapy intervention, attachment security increased (by reducing attachment avoidance in families) and NSSI behaviors decreased. In sum, when conceptualizing NSSI, counselors should consider the client’s attachment style and the possibility of incorporating appropriate family members/caregivers in treating NSSI behaviors.

NSSI From a Family Systems Perspective

A family systems approach theorizes that an individual cannot be understood in isolation but only in context of the family (Adler, 1956; Bowen, 1978; Satir, 1983). From a family systems perspective, individual concerns, such as NSSI, can be conceptualized as a family issue and considered a symptomatic pattern of coping with an inappropriate balance of communication and behaviors in the family (Bowen, 1978). For example, a teen or young adult client may not understand how to cope with family problems and resort to becoming symptomatic of the family issues through NSSI behaviors. The client struggling with NSSI may need to renegotiate how to address stressful situations and issues within the self as well as with the family to experience therapeutic relief of the painful emotions and maladaptive behaviors driving NSSI.

In keeping with the need to address the family system issues that may be contributing to the client’s symptomatic behavior of NSSI, counselors can include family members or caregivers into counseling sessions to improve the client’s level of attachment. As previously presented, clients struggling with NSSI often have a history of family problems, and family factors may influence NSSI. Reciprocally, NSSI itself may also influence family dynamics, demonstrating the cyclical systems pattern of influence (Hoffman et al., 2010). Given the reciprocal relationship that NSSI and family functioning have on each other, it seems appropriate to address NSSI from a family systems perspective, including appropriate and available supportive family members or caregivers in treatment.

Hoffman, Hinkle, and Kress (2010) suggest that therapists assist the adolescent who self-injures with achieving his or her goals for treatment while also helping family members understand and manage the client’s NSSI, which could address and decrease overall stress in the family system. Counseling approaches that externalize NSSI behavior as the problem may be helpful in supporting adolescents who self-injure as well as their families (Hoffman et al., 2010). Just as many approaches to counseling individuals exist, many approaches to family therapy exist which can work toward creating healthy interactions.

One approach to family counseling that might be considerably helpful for the treatment of NSSI is emotionally focused family therapy (EFFT; Schade, 2013). The goals of EFFT include the following: (a) improving family communication, (b) providing safety and empathy to allow vulnerabilities to be shared, and (c) increasing emotional attachment security between the client and caregivers (Johnson, 2004). The application of EFFT to families with children and adolescents has been shown to be effective in some research (Bloch, 2007; Johnson et al., 1998), and further calls for future research have been made to continue building evidence in using EFFT in treating NSSI (Schade, 2013).

Suggestions for Counselors Working With the Family

Numerous research studies have suggested that NSSI may be the result of a problem in family functioning and, as a result, insecure attachment styles (Fujimori et al., 2011; Hoffman et al., 2010; Kress & Hoffman, 2008; Trepal et al., 2006). Additionally, researchers have found that self-injuring youth are more likely to come from physically abusive or neglectful homes where they may have experienced physical or sexual abuse or come from a violent or high-conflict family (Fujimori et al., 2011; Trepal et al., 2006). Because of the potential of a high-conflict history of family members of teens and young adults who self-injure, it is of utmost importance to assess any safety concerns prior to including family members in a self-injuring client’s counseling. While research has indicated the potential for past family history of violence, parental divorce or loss within a family has also been found to be antecedents to self-injury, as have other stressors outside of the family (Trepal et al., 2006). After forming a relationship with the client who self-injures and assessing safety from a holistic perspective to ensure the safety of the client, including appropriate family members in treatment can be highly effective. Based upon our clinical experience as individual and family counselors who have worked with many clients engaging in NSSI, as well as a synthesis of the relevant research, we suggest the following approaches and interventions with clients struggling with NSSI and their supportive caregivers participating in family counseling.

Psychoeducation

According to family systems perspectives, each family member may have a unique and valid perspective on the NSSI of the client and because of this may experience a range of emotional responses to client’s self-injury, including fear, anger, frustration, or confusion (Fujimori et al., 2011; Trepal et al., 2006). Family members may have no idea why anyone would self-injure and therefore may benefit from psychoeducation in order to be appropriately supportive of the client. Because of the range of possible emotions, a family member may completely withdraw from or attempt to gain control over the client who self-injures. Since communication and patterns of communication are vital issues in systemic theories suggested for NSSI treatment, responses of avoidance or excessive control may increase the conflict felt within the family or decrease the quality of communication that needs to occur between the client and family members (Yip, 2005).

Postvention

Although NSSI is not a suicide attempt, family members’ possible interpretation of a client’s NSSI as a suicide attempt indicates a possible benefit of turning to literature on working with parents whose child has attempted suicide (Trepal et al., 2006; Yip, 2005). As parents may be unclear why the client is engaging in NSSI, they may need support in working through their own emotional reactions, possibly mourn for the family network, and cope with feelings of isolation or shame and guilt. Just as the teen/young adult client who engages in NSSI does not have adequate coping skills, it is logical that their parents and family members may not either. Family members may benefit from being directed to appropriate resources, such as counseling or a support group, in order to openly express their feelings and concerns regarding client’s NSSI apart from the client to reduce the risk of damaging the relationship with the client. In preparing to support a client who self-injures, family members should be taught a no-fault approach, removing blame from the family and the client (Trepal et al., 2006).

Resource for Caregivers: 10 Points to Understanding NSSI

During moments of emotional crisis when clients are engaging in self-injury, such as cutting, parents and caregivers more often than not appear in therapy as distressed and desperate to understand how to help their sons and daughters. While each family struggling with NSSI is uniquely different and deserves thorough individualized care throughout counseling, some common themes and concerns have been consistently observed in clinical practice among many families learning about NSSI for the first time. Caregivers need basic information to understand NSSI and prepare to engage with the client in family therapy appropriately. As previously discussed, family systems therapy with an attachments lens would address the value of easing caregivers’ anxiety in order to be more supportive and therapeutically beneficial. We have provided a list of 10 brief points to understanding NSSI and suggestions for appropriately supportive caregivers based on the presented literature earlier in this article, as well as our clinical experience, as a resource for counselors to provide and discuss with caregivers. These suggestions are in no way a substitute for counseling but are to use as a resource to caregivers. Any form of self-injury must be taken seriously and addressed through ongoing counseling. Although NSSI is not a suicide attempt, continual assessment for suicidal ideation by a mental health professional must be ongoing.

1. Seek support from a licensed professional who specializes in NSSI.

A counselor will determine whether including family is appropriate at this time. The counselor may suggest a referral to a medical provider to address any medical concerns. This may also include referral for a psychiatric evaluation due to possible mood disorders or anxiety. If the client is a minor, please keep an open mind. If not a minor, allow for the client to discuss options openly if he or she chooses.

2. Client’s behaviors may get worse before they get better.

This is common as painful issues are worked through in counseling and coping strategies are changing. If severe changes occur and suicidal thoughts are suspected, contact a professional counselor or take the client to an emergency room immediately.

3. Do not shame client for a relapse in NSSI.

NSSI is a method that the client has formed as a way to cope with life. Change is difficult and takes time. A relapse in NSSI does not mean that the client is not working hard in treatment. Be patient and understand that there is no given timeline as each individual is highly unique.

4. Have support lined up for the parent/caregiver.

NSSI is very difficult as a caregiver to witness. Caregivers need therapeutic support to process their emotional responses to client’s self-injury. This is a good time for the caregiver to build a relationship with an individual therapist or regularly attend a support group.

5. Each individual’s reasons for self-injury are different and motivations for NSSI are not always the same.

Caregivers would be misguided to assume to always know why the client is engaging in NSSI. The client needs patience and open listening from caregivers as well as a safe, nonthreatening environment. The client may not have a clear awareness of what they are feeling or why they feel that way at this time, and that is OK.

6. The client’s self-injury may not be a suicide attempt.

Displaying shock and extreme emotional reactions could make client’s emotional state worse and increase severity of NSSI. Regardless of whether the client’s NSSI is suspected to be a suicide attempt or not, it is appropriate to seek professional help immediately in a calm manner. Reactively yelling, unintentionally shaming, or accusing the client of being “attention seeking” for hurting themselves creates a barrier for necessary open communication.

7. Do not punish or place ultimatums on NSSI behavior.

Methods of control will most likely worsen uncomfortable emotions that the client does not know how to cope with in a healthy manner yet. With this in mind, appropriate boundaries are still needed, and the client is not excused from appropriate rules and responsibilities. Suddenly providing the client with unfounded special privileges will be counterproductive as this removes opportunities for growth in self-confidence. Work with the client to consider if any adjustments need to be made at this time, such as taking a semester off from college.

8. Your loved one may use temporary alternatives to NSSI to stimulate a similar pain or visual response without causing bodily harm.

Methods such as holding an ice cube to arm or drawing lines with a marker where the client usually cuts are some common replacement behaviors that provide alternatives to cutting. This is an appropriate short-term coping strategy while the client develops appropriate coping skills and may not last forever. This is a brief harm-reduction strategy.

9. Treating self-injury seems to be most effective when clients can improve attachment security.

Improving attachment security means working toward improved self-esteem, ability to articulate feelings, and have a mutually respectful and trusting open relationship with others. This may mean working through past and/or present family issues. If appropriate, make every attempt to engage in family counseling with the client.

10. The client will continue to feel a variety of desirable and undesirable emotions.

The client will continue to experience emotions such as sadness, anxiety, and anger, even after NSSI discontinues. This is part of the human experience, and experiencing a full range of emotions is healthy and appropriate if safe coping strategies are in place. When the client is feeling a painful or undesired emotion, he or she may need help to identify an appropriate outlet, such as writing, listening to music, painting, talking, or exercising.

Case Illustration

To demonstrate the use of family therapy from an attachment perspective and providing caregiver resource of 10 tips to understanding NSSI, the following case illustration is presented below. This case demonstrates the attachment style and attachment needs of the client, strategies of psychoeducation and postvention in working with the family, and a restructuring of communicating attachment needs through family therapy. Identifying information has been left out or changed to maintain confidentiality.

Myra is a 16-year-old female presenting to counseling individually due to significant anxiety and depression. She is highly intelligent and has near perfect grades in all of her advanced high school courses; however, lately she has not been able to focus despite hours of concentrated effort and her grades have suffered. Myra is also a former champion in her athletic field, yet due to recent lethargy, she has lost her ranking. Myra’s mother complains that Myra is not who she used to be, as she has been withdrawing from the family and not engaging with her siblings. Her parents remain married and describe their relationship as loving and supportive, which Myra independently agrees with. Myra is described by her parents, family members, friends, and teachers as a strong positive role model. Myra does not have any history of physical or sexual abuse and denies any experimentation with drugs, alcohol, or sexual acts. In addition, Myra does not meet criteria for BPD.

For the past 6 months, Myra has been experiencing panic attacks and moderate symptoms of depression. Due to the intensity and frequency of Myra’s panic attacks as well as persistent high level of anxiety and tearfulness, Myra was referred to a psychiatrist and began taking an antianxiety medication to allow Myra to feel she could function at a higher level, therefore allowing her to continue in school and participate more fully in counseling. Although Myra denied any self-injuring behaviors in the beginning of the counseling process during a time when she was alone with the counselor, after four sessions of discussing high anxiety levels and panic attacks that were addressed with mindfulness and Cognitive Behavioral Therapy (CBT) interventions, Myra disclosed that she had been engaging in NSSI with superficial cutting to her wrists using various objects. She further disclosed that she was concealing marks with multiple bracelets and long sleeves, which she displayed to counselor voluntarily with tears in her eyes. Myra was not experiencing any suicidal thoughts.

Myra originally did not want to inform her parents of the NSSI as she felt they would be disappointed in her. However, after supportive discussion about the importance and need to include her parents in this conversation due to safety, limits to confidentiality, and Myra’s status as a minor in the custody of nonabusive parents, Myra agreed to disclose her NSSI behaviors to her parents with counselor’s support in session. Like many parents, Myra’s parents were shocked in hearing that Myra was cutting herself approximately once a week. They originally feared that Myra was suicidal and, in panic, began to bombard her with questions ranging from “what’s wrong” to “what did we do wrong?” and speaking out loud about their concerns of Myra’s siblings finding out about this as they both had always been told to follow Myra’s example. Her parents’ initial reactions elicited feelings of guilt and shame with Myra, and she withdrew from the conversation.

Myra’s parents had not known of anyone personally who engaged in NSSI before. They misunderstood the behavior in a way that could have been more damaging to Myra. Therefore, the counselor provided psychoeducation to the parents regarding NSSI with our list of 10 points as well as resources to additional support for parents including individual counselors and support groups. The counselor modeled reinforcing patience and unconditional positive regard when discussing NSSI with Myra in front of her parents and held a discussion of adjusting the treatment approach to incorporating parents in counseling. Myra agreed to include parents in future sessions with the condition that she could continue to have occasional individual sessions with counselor, a condition all parties agreed to.

The counselor held a brief session with parents without Myra (but with Myra’s knowledge) later in the week to process parents’ feelings and reactions to Myra’s NSSI. Through engaging parents in a postvention conversation separately from Myra, parents were able to openly share their personal reactions and fears without risking potential emotional harm for Myra. Both parents visibly appeared more relaxed after discussing NSSI with the counselor and reported feeling more buy-in to the process of family counseling with the clarified understanding of how they could support Myra in the healing process. The mother was referred to a separate counselor to have continued individual support throughout the process, and consent was given for counselors to collaborate as needed. After the combination of psychoeducation and postvention, Myra and her parents understood that Myra was struggling more with attachment insecurity as she experienced painful self-doubt and mistrust of others to unconditionally love or accept her. Myra used NSSI to cope with feelings she could not articulate in the past for various possible reasons. Parents understood that treating NSSI would not be a quick fix as healing underlying attachment wounds takes time and requires consistent, trusting support from the parents to work toward long-term healing.

In the following weeks, Myra began to speak more openly with her parents in family counseling, with the counselor “catching the bullet” when parents made comments to Myra that were taken offensively. With the safety of the family sessions, Myra was able to express to her parents the immense and impossible pressure to be perfect she felt when parents corrected her siblings with the instruction to look up to Myra. Myra was able to identify and eventually articulate that due to this perceived need to be perfect, she felt that parents’ love was conditional and that due to parents’ perception that Myra was perfect, she did not need as much attention as her younger siblings, leaving Myra feeling lonely, ignored, and neglected. Although Myra’s parents were indeed loving caregivers, Myra’s perception was that she was loved and supported for perfect performance and behavior and that if she were to no longer be perfect, they would not love her as much. Myra’s conditional self-acceptance combined with feeling neglected led to Myra retreating from her family. Myra experienced an anxious-avoidant attachment style. Myra was able to increase attachment security through the corrective experience of sharing her fears and imperfections with her parents in family therapy and having family members respond with more consistent reassurance to their unconditional love and openness to talking with her. While she occasionally continued to experience urges to engage in NSSI, she had restructured her relationship with her family in a way she felt increasingly less pressure to be perfect and more comfortable talking with her parents when she was feeling anxious, seeking their support when she was struggling with urges to self-injure, and informing them of increasingly rare relapse occurrences of NSSI. In return, her parents gained the awareness that unintentional demands of perfection were very difficult for Myra, and they learned alternative strategies to parent younger siblings without instructing them to be just like Myra. In addition, Myra’s rate and intensity of panic attacks greatly decreased over the coming months as the family maintained a more positive communication pattern.

Conclusion

Throughout a thorough review of literature on working with teens and young adults struggling with NSSI, previous research has found that NSSI is correlated with insecure attachment styles, suggesting that approaching therapy from an attachment perspective is highly beneficial. While there is an array of suggested clinical practices for working with teens and young adults struggling with NSSI from an attachment perspective, including supportive caregivers could aid clients struggling with NSSI to address emotional attachment needs with supportive caregivers to foster improved attachment security and long-lasting change. It is further noted that supportive family members may be able to support the client more therapeutically when the counselor provides psychoeducation and postvention. The 10 points to understanding NSSI for caregivers resource have not been formally researched in practice; however, points are strongly based on evidence-based research. Future research is suggested to further investigate this tool as a supplement to family counseling in clinical practice when working with clients struggling with NSSI.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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