Jennifer Muehlenkamp, PhD, from the University of Wisconsin-Eau Claire describes the difference between suicidal and nonsuicidal self-harm and explains how we came to use the term “nonsuicidal self-injury” (NSSI). She also discusses what characteristics of self-injury place someone at greater risk for attempting suicide.
Today there is still confusion among a lot people about the differences between suicide and nonsuicidal self-injury. Although nonsuicidal self-injury (NSSI) is a form of self-harm and a risk factor for attempting suicide, the two behaviors should not be confused and those who self-injure should not be assumed to be “suicidal.” In this episode, we discuss how the onset, frequency, method, and function of self-injury are related to risk for suicide attempt.
Follow Dr. Westers on Instagram and Twitter (@DocWesters). To join ISSS, visit itriples.org and follow ISSS on Facebook and Twitter (@ITripleS).
TRANSCRIPTION GRACIOUSLY PROVIDED BY LIAN J. ARZBECKER (THE OHIO STATE UNIVERSITY)
The Psychology of Self-Injury Podcast
Nonsuicidal Self-Injury vs. Suicide, with Dr. Jennifer Muehlenkamp
January 1ST, 2021 | 41:18 | S1:E2
Dr. Westers: How can you tell if self-harm behavior is suicidal or nonsuicidal? Today, there is still confusion among a lot of people about the differences between suicide and nonsuicidal self-injury or NSSI for short. So, what is the relationship between NSSI and suicide, and why is it important to differentiate between them? What characteristics of self-injury, if present, place someone at greater risk for attempting suicide? What about protective factors? To answer these questions and to provide insight into how we came to use the term, NSSI, I'm joined today, from the University of Wisconsin-Eau Claire, by Dr. Jennifer Muehlenkamp.
Welcome to The Psychology of Self-Injury Podcast: a resource for parents, professionals, and people with lived experience. I'm your host, Dr. Nicholas Westers, Clinical Psychologist at Children's Health, Associate Professor at UT Southwestern Medical Center in Dallas, Texas, and Chair of the Media and Communications Committee of the International Society for the Study of Self-Injury, or ISSS or simply I Triple S.
I met Dr. Muehlenkamp at my first I Triple S conference in Vancouver, Canada. She had only recently given birth and there she was, infant in her arms, giving a professional presentation. I made it a point to introduce myself and sit with her at lunch. I'm fortunate to have since co-authored a couple of papers with her. Dr. Muehlenkamp is a professor of psychology at the University of Wisconsin-Eau Claire, a licensed clinical psychologist, and a past president of I Triple S. She has been working in the field of suicide prevention for over 20 years, specializing in the study of nonsuicidal self-injury. Her early work helped to characterize NSSI among youth and young adults and to clearly differentiate NSSI from suicidal behaviors. Currently, Dr. Muehlenkamp is focusing on improving our understanding of psychological factors that increase —and protect against—risk for suicide among those who are engaging in NSSI. Thank you, Dr. Muehlenkamp, for joining us today.
Dr. Muehlenkamp: Yeah, thanks. It's nice to be here.
Dr. Westers: To start things off, how did you become interested in researching self-injury to begin with?
Dr. Muehlenkamp: Yeah, well, I get that question a lot of times. And how it came to be, really, was through some unique experiences I had as an undergrad and then early in my graduate career. So, as an undergraduate, I was a psychology major and my university offered an opportunity to job shadow a clinical social worker. And the person I got paired up with happened to be an individual who was working with a lot of adults and some young adults who struggled with borderline personality disorder. And he was also just introduced to Marsha Linehan's book on dialectical behavior therapy—so, I'm dating myself because the book had just come out—and so I was able to sit in on some of the learning teams that he was coordinating with that. And then as well as going along to visit some of the clients, there was one client in particular that we interacted with regularly who had just turned 18—so the person was very close in age to me—and had a long history of self-injury. So, to be able to see that you can see self-injury as unique and not being suicidal, that was really my first entry into that idea.
And then certainly there's personal histories in terms of the fact of knowing friends who had struggled with depression and suicide. And so, I went into my graduate programs really wanting to study depression and eating disorders um, and to find a way to help. And it was through reading some more literatures, and then growing from that clinical experience, that I decided that I wanted to look at this self-injury behavior and to see if it was actually different from suicide.
Dr. Westers: I remember when I was in graduate school, and actually reading some of your work and wanting to explore self-injury for my dissertation research. And our university was misinterpreting nonsuicidal self-injury as suicide—and at first would not let me pursue that research because in their eyes, it was too high risk because the individual participants would be classified as suicidal. And we know that's not the case. So, based on your experience in your research, what is the difference between nonsuicidal self-injury and suicide or suicidal behaviors?
Dr. Muehlenkamp: Yeah, I think a lot of people struggle with this differentiation. I always say at the core of it is the desired outcome of the behavior. And a lot of times we talk about that as being intent underlying the behavior. And what we see is that the nonsuicidal self-injury, they're behaviors that are meant to help someone manage or deal with what's going on for them. And so in a lot of ways, it is seen as a coping strategy and the individuals do not expect the outcome to be death; whereas when someone is attempting suicide, they are wanting that behavior to result in their death. And so, the intent or the desired outcome of the behaviors is a really critical piece.
But there is some other really important features that differentiate them as well. One is that the self-injury, oftentimes, is relatively minor in terms of the injuries that are produced and they're easily cared for—and that allows the behavior sometimes to be kept more secret as well. But that superficial injuries are a key component of it, whereas many suicide attempts have a more lethal component behind them. The other thing is that some suicide attempts will have an immediate injury, or a lot of them with how youth will attempt suicide, they usually use methods that do not result in a direct, immediate injury; whereas with self-injury, one of the key defining features is that it results in immediate tissue damage.
Some other key differences between self-injury and suicide attempts really are discovered by talking with the individual. So, it's the primary outcome of the behavior, which I mentioned before, and then it's also some of the states beforehand. So we know that individuals before they engage in an act of nonsuicidal self-injury, they're often feeling angry, they're frustrated, they're agitated—it tends to be what we call high-arousal negative emotional states. For individuals who are attempting suicide, research is suggesting that the emotional state right before the act is more likely to be characterized with an additional sadness, hopelessness, despair, feeling stuck and trapped in the situation with no way out. And while some people right before a suicide attempt might also be agitated and angry, they also have that level of despair and hopelessness that we tend not to see for people before they engage in an act of self-injury. So, there's some differences in the emotional state and just that phenomenological experience that the person has that also helps to differentiate them.
Dr. Westers: And I'm reminded of a paper you wrote, back in I think 2004, talking about one of the key differentiators was attitude toward life. And it sounds like that despair, those who self-injure have a better attitude toward life and less despair—more hope even if they don't feel fully hopeful—than those who attempt suicide.
Dr. Muehlenkamp: Yes, that's what we've consistently found. And in that particular study, we measured attraction to death and attraction to life, and it was certainly those who engaged in self-injury had a much stronger attraction to life. And I think that also underlies the fundamental differentiation between these two behaviors: is that self-injury is used by individuals to cope with what I call aversive internal states. So it could be self-hate, it could be feelings of frustration, it can be for emotional control, it can help some people focus—so there's lots of internal states that the self-injury helps to, help the individual to manage.
Dr. Westers: A lot of people listening are new to the term “nonsuicidal self-injury” or “NSSI” and may commonly use “self-harm” instead. And how did we come, historically, to the term “nonsuicidal self-injury” or “NSSI”? Can you take us through that? Because that's a newer term that a lot of people may not be familiar with.
Dr. Muehlenkamp: Yeah, absolutely. So, it's, it's a, for me, it's a fun story because it's how experts and professionals in the field come together and make some decisions that then shape, really, the future direction of everything. So, I'll start with the conceptual reasons to why we decided to use the term “nonsuicidal self-injury.” And this was an expert consensus decision that was made; there was a small team of us who were all working in the field—when the field was still very, very young—and we were able to all get together for a weekend kind of retreat where we talked about the state of studying this behavior and trying to come up with some agreements to move the field forward so that we were all studying the same thing. And that's where the term “nonsuicidal self-injury” was really coined and accepted, and we all said yes, we're going to move forward with this. And the reason for that was because the term “self-harm” is very broad—and in many ways, it's all-encompassing.
And when we think of the self-damaging behaviors that people can engage in, it can range from what we consider indirect, low-lethality behaviors that really sometimes do not even result in immediate tissue damage but are unhealthy for individuals—so things like substance use, disordered eating behaviors, and aspects like that—which are potentially self-destructive, but they aren't leading to an immediate injury. All the way along a continuum to certainly a life-threatening injury. And so you have everything in between there and that all can result in, and people can refer to that as, “self-harm.”
So to be able to really understand this unique phenomenon of people who are engaging in self-cutting, self-burning—other behaviors that resulted in immediate tissue damage that were not intended to result in one's death—we needed to have a term that really captured that. And so that's why we chose the nonsuicidal part of the terminology because we wanted to make clear that the self-injury—even though potentially quite damaging, because if you're cutting yourself there's bleeding and injuries and aspects like that—it's nonsuicidal. So, it's clear that the person is not wanting it to result in their death. And then it's self-injury, meaning it's self-inflicted. So, that's really how the term kind of emerged and why we decided to go with nonsuicidal self-injury or NSSI over self-harm. Because it's more precise, it's more specific—whereas self-harm encompasses a much broader range of behaviors.
Dr. Westers: A number of individuals and researchers in the field who continue to use the term “self-harm” argue that when we differentiate it from suicide—by calling it nonsuicidal self-injury—then there's this implication that maybe they may not be at risk for a future suicide attempt. And that's one, one criticism. What would be your response to that?
Dr. Muehlenkamp: I think there is some risk by saying it's nonsuicidal, that people would lower their concern. I have not found that to be because when people think of nonsuicidal self-injury or NSSI, the typical behavior that comes to mind is cutting. And most people do not see cutting as something to not be concerned about—or to not be concerned that it could potentially lead to or transition into some risk for suicide, just because some people talk about using cutting as a method for suicide. So, my reaction to that is I think we're at a point in the research where we can feel pretty confident that we know that self-injury is associated with risk for suicide—but it's also distinct and separate from.
And for me, it's no different than being able to classify Major Depressive Disorder from general sadness in terms of understanding someone's risk and severity. If you tell me someone is depressed, I'm going to be concerned about them and want to follow them, possibly intervene, and also monitor for suicide risk. So if you tell me someone's engaging in nonsuicidal self-injury, I'm concerned about them, I want to check in with them, and I want to monitor them for possible suicide risk. So for me, it's just a way to be more precise in our field so that for those who are not suicidal, but who engage in self-injury, we can really understand the factors impacting that behavior as well.
Dr. Westers: A number of individuals that do self-injure and have not experienced suicidal thoughts when they self-injure—and have never experienced suicidal thoughts when they self-injure—have had experiences where their behavior has been misinterpreted as a suicide attempt or reflecting suicidal ideation. What feedback might you have for people listening that may come across individuals who do self-injure in how they might differentiate it from suicide?
Dr. Muehlenkamp: So one of the things that I recommend, mostly to a lot of the mental health professionals that I train and provide workshops to, is that how you approach the question becomes really important. And we want to, just like with anything, try and not to make assumptions about the behavior. So, I have a couple of thoughts running around in my mind right now. The first is that as you approach asking about the behavior, I really recommend that you just start with, “tell me how this works for you.” Or, you know, if someone's discovering an injury or something like that, to just to ask and, and say, “you know, are you willing to let me know what this is about?” You know, in a nonjudgmental way—we need to think about the words that we would use.
But to really ask the question to allow the individual to explain the behavior to them. And if they're concerned about suicide risk, one of the key questions I always go to is—to really show that you understand it may not be about suicide and to start with asking and to basically set the context and just say—“I understand that your cutting is not about wanting to kill yourself, but I am concerned about you and I would like to know more about when it occurs.” Or “I would like to know if there are times when thoughts of suicide do cross your mind—either while you're injuring or at times when you're not injuring.” Um and I think that's a really nice way to approach it because it communicates the idea that you recognize that behavior is not a suicide attempt, but you open the door to be able to explore whether there's any type of suicidal thinking or risk possibly present.
At the same time, I want to go back to the start of your comment in that we have studies that do show that individuals are very hesitant to disclose their self-injury because they do fear it'll be misinterpreted as a suicide attempt. And there still tends to be a lot of stigma and judgment around self-injury that also prevents people from wanting to talk about it and share about it. Because again, people assume that there's some kind of, um suicidal intent that might be there. Or they assume more serious psychopathology, meaning mental health disorders, that people might be struggling with. And individuals who engage in self-injury are just like the population for many other difficulties: is that there's a range in severity, there's a range and co-occurring problems and issues that come along with it, and there's a range and severity of possible risk for suicide too.
When you look at combining all of the data together, it's estimated that around 25%—maybe you could squeak up to about 30%—of the population of people who report having engaged in self-injury, report having significant suicidal thoughts and/or possibly also having a suicide attempt. So when you think of, let's say, the thousands of people who engage in self-injury, around 25% of them are also at significant suicide risk. And I think that's important to recognize because we know that self-injury is a very strong risk factor for suicide attempts—and we have some longitudinal studies to suggest that—but it's a small portion of those who engage in the self-injury.
Where it gets confusing is that if you look at the population of people who report having attempted suicide—so now you're taking the thousands of people who have actually already attempted suicide—it's estimated and again, it varies, but it's estimated around 60 to maybe 75% of people with a past suicide attempt have a history of self-injury. So depending on the lens that which you look at the data, people walk away with different concerns about suicide risk. And so what I say, if we're coming from the angle of “who's engaging in self-injury?” there's such a wide variety there that it's a small subset—a concerning subset and still significant, but smaller than what I think some people really understand—that are at really significant risk for suicide. But I'm not saying that to downplay the risk; I'm just saying that to set the context, because regardless, if someone's engaging in self-injury—by the mere fact they're doing that—it's a sign that they're really struggling with something. And we know from our data that even having one instance of self-injury pushes someone up a little bit in terms of their risk for possible suicide.
Dr. Westers: Yeah, I've heard of individuals, their behavior being misinterpreted as suicidal—whether they're at school or at the emergency department—in receiving improper care or being treated differently. You had mentioned stigma, where some I have read about having acknowledged that it was a suicide attempt rather than nonsuicidal self-injury in order to be treated better—when in fact it was not suicidal in anyway. And we already know that individuals who attempt suicide are often misunderstood even in clinical settings like the emergency department and may receive lower levels of care than those who are in the department for, emergency department for other reasons. And so I think it's extra important for us to consider as one of the unintended consequences of misunderstanding the behavior, but also like you had mentioned, not under-reacting either—we want to make sure that we assess some of the intent like you had mentioned earlier. So, what characteristics of self-injury, you had mentioned some, place certain individuals at greater risk for attempting suicide?
Dr. Muehlenkamp: Yeah, so, we're at a point in the field where we're starting to see consensus across a few different indicators. And what I try to focus on is—there's certainly the typical suicide risk factors that people can assess for that would be present like your, your hopeless, your despair, feeling trapped—but what I'd like to really focus on are the self-injury characteristics specifically. So, one of the things we know—and this has been replicated across a number of large-scale studies—is that the frequency of episodes of self-injury has what we call a curvilinear relationship to risk for suicide.
So, the first point in that, is that generally, across-the-board, the more that someone engages in self-injury, the greater their risk appears to be. However, within that increasing risk, there's a window where when people get to the point of around 20–50 episodes of self-injury—and I say episodes or acts of self-injury because that means the number of times they've self-injured and not necessarily the number of injuries they have, so it's the number of episodes or times that they have engaged in self-injury—if it's between that window of 21–50, across many studies we see that that's when the risk is highest. Risk still stays elevated beyond 50 episodes, and is definitely elevated before 20, but the period of highest risk is that 20–50 episodes. And we're still trying to figure out why that particular window seems to have that high of risk. So, I don't have any answer for that, but we just, that's important to track. And so certainly as frequency increases, but within that window, we've got greatest risk.
We also know that the number of methods or different ways in which someone engages in self-injury also matters. So, we know that many people have a preferred method of self-injury, but as they continue to engage in this behavior, they will engage in other forms of self-injury. And so as they add the number of forms and methods they use to injure themselves, that's associated with greater risk too. So, the greater the number of methods used in different ways in which they self-injure, that's associated with increased risk.
We also know that the reasons for why people engage in the self-injury is associated with risk too. And I find this personally really fascinating because we know that the number one reason why people say they engage in self-injury is to help manage their emotions. And so we call that affect regulation or emotion regulation. And self-injury does serve that purpose. However, some data that I have with some colleague—and from some other studies that have been connected too—that motivation does not appear to have a consistently strong relationship to suicide. So, it's some of the other motives that people engage in self-injury for that do relate to suicide attempts prospectively. One is when people are saying that they're using the self-injury to avoid attempting suicide or to stop themselves from attempting suicide. That consistently emerges as one of the strongest reasons that's connected to a future suicide attempt. And the way I think of that is, well, it makes sense because if a person is already at the point where they're thinking of attempting suicide and they're so close that they need to do something to stop themselves from it, that that's a pretty significant warning sign. Um and it's also concerning for me, as a clinician, that they're using a type of self-injury in order to stop themselves from a lethal self-injury. So you're, you're walking a fine line there. But when people are saying that they use the self-injury to not kill themselves, you want to be particularly concerned.
We also see that when people report using the self-injury to stop dissociation, or to stop feeling numb—or to try to feel real and remind themselves that they're real, they exist, they're, you know, present on the planet—that that's associated with increased risk for suicide as well. And so that need to use the self-injury to remind oneself that they're real and no longer numb, that should pique some concern. And then the third one that emerges very strongly too is when people use the self-injury to self-punish. A lot of people forget that the second most common reason for engaging in self-injury is self-punishment. And what drives that a lot of times is a lot of self-criticism, self-hate, lack of self-worth. And we know from the suicide research literature that self-hate is often a common driver of suicidal behavior. So, when you pair a motivation of self-hate with an already self-injurious act, it makes sense that could elevate risk.
One thing that we have found that I think is really interesting is that with the reasons for self-injury, some people report that they engage in self-injury to help activate resources in their environment and to get people to take their distress seriously. And in a recent study that a colleague and I completed, we found that for people who reported that their self-injury was effective in accessing resources and having people take their distress seriously and kind of help support them and come to their aid, that that was associated with a significant decrease or a reduction in the risk for suicide. And part of that is because they're activating resources, they're getting the supports that they need. And so being able to track and monitor the functions and reasons for why people engage in self-injury's important.
And then I'll mention one more component that consistently emerged and that is the severity of the self-injury. And the severity of the self-injury is mixed in with the number of methods in the frequency of the self-injury. But like I said earlier, most self-injury is easily cared for with superficial wounds by the individual and does not need medical attention. But when the self-injury starts to get to the point where it requires medical attention, that's where we see a strong relationship to a future suicide attempt as well. So, needing medical attention is our marker of severity and as the self-injury starts to get to the point of starting to need medical attention, that risk for suicide increases.
Dr. Westers: So, a number of factors: severity in need for medical attention, frequency of episodes, number of different types of methods, as well as specific reasons for self-injuring or the specific functions. One question I've heard come up quite a bit is location. Does it matter where someone self-injures? If they're hiding it? Or specific parts on their body? Is that linked in any way to suicide risk?
Dr. Muehlenkamp: I think that's a great question; I get that a lot too. There have been just a couple studies, one or two that immediately come to mind for me, that have looked at location in relation to suicide risk. So, I'm often hesitant to suggest that as a potential factor for suicide risk just because we don't have a lot of great data on it. But what I can share with you from those studies is that it's been suggested that, specifically for cutting, if the cutting occurs not on the arms—because the most common place for cutting and even burning behaviors are on the forearms or even the upper arms—that if that behavior is occurring in other areas of the body, which also makes it easier to hide and disclose, that that was associated with some increased risk for suicidal behavior. And I think clinically, and just really anecdotally, it makes sense to me that if someone is engaging in self-injurious behaviors, particularly cutting in areas that are close to potentially life-threatening areas anyway—so near arteries or other significant areas where you could inadvertently cause a lethal injury—that certainly is very concerning. And the more secret that behavior is—so the easier it is to hide from other people and not have accidental discovery—to me, I think that adds another layer of concern just in general. But I can't say that that is definitely a risk factor or a sign to monitor for suicide risk.
Dr. Westers: You had published a study recently within the last couple years about onset of the behavior in early onset, and I believe that was under age 12. Can you tell us a little bit about what you found in that study in terms of onset and duration of self-injury and its relationship to suicide attempt risk?
Dr. Muehlenkamp: Yeah, and the study you're referencing has also been replicated by some other researchers in the field too. So again, it's a consistent finding. So, what we did is we had a sample of I think close to or just over 4,000 university students and we asked them about histories of self-injury. And what the data showed is that for individuals who reported engaging in self-injury prior to or up to the age of 12, had the greatest risk for certainly having engaged in self-injury the longest—which makes sense because they started earlier than the rest of the sample—they had more frequent self-injury, more severe self-injury, and they were also significantly more likely to report having made a suicide plan and having attempted suicide compared to the other age groups. And the other age groups we had were a typical age of onset, which were those from age 13 through age 17 and then those who had a later age of onset, age 18 and older.
And what we found basically is that the earlier age at which self-injury begins, the greater the likelihood for having made a suicide attempt in their lifetime, as well as in the past year. And so certainly the longevity of engaging in self-injury is related to suicide attempt behavior. And part of the reason we think that may be is because self-injury results in, like we said, injury to the body, and so it has physio, your body reacts physiologically to that. And part of that physiological reaction then habituates over time. And there are theories within the suicide research that suggest that in order to get to the point that you can engage in a lethal act of self-injury, so a suicide attempt, you need to acquire the ability to really engage in lethal injury. And that means you have to habituate to pain, to the sensitivities that can occur, and to the fears that often protect us from engaging in lethal acts. And so some of the hypotheses are that self-injury contributes to that habituation.
And so the longer you engage in the behavior, we have some people who report they need to engage in the self-injury more frequently, or more severely, or change up their methods in order to get the same relief that they've experienced from the self-injury. And so that supports the idea that the self-injury contributes to a habituation processes that might then lead to the risk and increase their ability to carry out a potentially lethal act of self-injury or a suicide attempt.
Dr. Westers: I can imagine some people listening to this, especially parents of children who self-injure, may be pretty intimidated by the topic and being able to differentiate if your child is self-injuring with suicidal intent or without suicidal intent. And I think taking a more hopeful approach, going back to attitude toward life. What factors or characteristics would you say are protective against suicide attempts among those who do self-injure?
Dr. Muehlenkamp: Yeah. Well, I think what's really important is to recognize that because someone is self-injuring, they're certainly struggling with something, but they still have a wealth of resources that we can draw upon. And one of the—I don't know if you want to say a benefit but—one of, I guess, the upsides is that youth who are engaging in self-injury are trying to find a way to cope with what they're going through. And so for me, that alone—I know it sounds a little contradictory but—there is an element of hope there for me. Because I'm saying okay, they're trying to cope.
Some other protective factors that we know is that certainly when youth receive a supportive response to disclosures of self-injury—or even accidental discoveries of self-injury—that those supportive responses, and particularly from parents and guardians, is a hugely protective effect. We have other colleagues in our field who I think are also going to be contributing podcasts that talk about the very valuable role of the parental person and the guardian in the youths' lives—even more so than peers. And so certainly helping parents and guardians to understand what's going on in playing an important role in that youth's life is really protective.
For the youths themselves, certainly our general protective factors, our youth who are engaged and have some other positive things that are happening in their lives—so whether it's sports that they're involved in that they're having some success with, some artistic expression that they have some success with, connection to peers—those are protective factors as well. As well as I think honoring their resilience. And again, it can seem contradictory to think of it this way but trying to also look at times where the youth were struggling, and maybe had an urge to self-injure but did not self-injure. That's where you have the window of resilience because that's where they engage in something else, an adaptive coping strategy, to get through that moment. And so being able to work with them and help them, whether you're a clinician or a parent, to find those windows of resilience and really build on those I think becomes important as well. But as far as specific features of the self-injury that indicate protective factors—researchers really haven't looked at that component because most people see the self-injury as a maladaptive, negative behavior that we don't want youth engaging in. The only thing that's really come out specific to the self-injury is when it's being used to try to activate those resources in the environment. That seems to reduce risk for suicide when it's effective in doing so.
Dr. Westers: That's great. Would you say those same protective factors for youth extend to young adults, like college students and adults beyond their 20s that self-injure?
Dr. Muehlenkamp: I would say most of them do, absolutely. And I would move for if we get to adults beyond young adulthood, the role of a parent and guardian obviously is probably not quite as important. But the importance of having social support and meaningful relationships is still very protective because we all benefit from having that sense of connection and well-being. But definitely, I think across-the-board for all wellness, when we look at protective factors is not only having meaningful social relationships, but it's also feeling a sense of, of a purpose and meaning in one's life and being able to contribute as well as having a sense of, I guess we call it self-efficacy in terms of being able to help affect your life in some ways—whether it's, you know, helping to cope with emotions or helping to make an environment more positive—those all play a really significant role. And so finding something that a person feels a sense of accomplishment in and a sense of self-worth and ability to contribute I think is really important.
Dr. Westers: And some psychologists call that building mastery as well [Dr. Muehlenkamp: Yes!], the self-efficacy.
We've covered a lot in terms of differentiating nonsuicidal self-injury from suicide, as well as the common characteristics of each—or those that could increase risk for suicide attempt among those who self-injure nonsuicidally. What else should we know about the relationship between self-injury and suicide that we haven't covered?
Dr. Muehlenkamp: Yeah, I think one thing that I've really seen as a sign of hope as well that has come out from some longitudinal studies as well some cross-sectional studies, is what I call the trajectory from self-injury to suicide. And we have research now to suggest that for the most part, self-injury and self-injury behaviors tend to happen first before a suicide attempt. For more than 90% of people who report having attempted suicide, the self-injury occurred first—if they have a history of self-injury. And what some studies have suggested, is that the time of onset of self-injury to the time of a first suicide attempt—if someone does attempt suicide—is an average of about 3 years. Now it's an average—so some people have shorter, some people it's longer—but for me, I think that's really important information because what that suggests is the earlier we identify and detect and discover self-injury, the earlier we can intervene, the greater the likelihood that we stop that progression to a potential suicide attempt.
And I just, I think it's really important and I think this also, it helps me as a clinician. It helps I think some people as parents and guardians to know that even if the person you know is self-injuring, may or may not become suicidal, if you discover it and it's pretty early on, you still have what appears to be a little—I call it wiggle room—or a little cushion of time until that suicide risk becomes really imminent. And so I think that's important because that can allow us a little bit of space to take time to be able to understand and intervene with the self-injury. Obviously as I've said before, you always want to be monitoring and concerned for suicide risk, but the fact that we've got a window of time also I think allows us maybe not to panic as quickly about suicide risk. So that's a recent research that's coming out that I find very encouraging.
Dr. Westers: Wonderful. Well based on our conversation today, what would you recommend to parents, professionals, and people with lived experience? Let's start with parents because a lot of parents worry that their child is at risk for suicide or are engaging in suicidal behavior if they're self-injuring. So, what feedback might you have for parents of children who have self-injured?
Dr. Muehlenkamp: Yeah. I think the first thing I have to do is just validate. And validate the fact that this is scary, it's uncharted territory, and there is concern. And so you want to always have, uh some level of concern for possible suicide risk. At the same time, your youth may really, they may not be at suicide risk at this time. And so I think what's really important is to validate for yourself the fear and the concern, and then also make sure you're in a calm space so that you can have a very open and nonjudgmental conversation and try to understand why the child or the young adult is engaging in the self-injury. And when you can have a shared understanding of why, then it opens up the opportunities to know how you can support them and have those conversations about seeking additional help and care to help them find other coping strategies that may really work.
Dr. Westers: And based on our conversation today, what would you recommend to professionals—whether clinicians like other psychologists, therapists—or researchers?
Dr. Muehlenkamp: Well so for clinicians especially, I think it's important to make sure that you're monitoring both the self-injury, as well as monitoring suicide risk. And we know that effective treatments for suicidal behavior are those that directly emphasize the behavior and what they call the “drivers” or the personal unique motivators for the behavior. And I think that's the same thing for self-injury. And so you want to make sure that you're actually addressing those factors that are both motivating and reinforcing the self-injury, while also continuing to monitor for suicide risk. And for clinicians, part of that then also involves having coping plans in place—or sometimes also referred to as safety plans for suicide risk—but coping plans and working on alternative coping strategies. And then I think for researchers, I think we're at the point where we clearly know self-injury's a risk factor for suicide, so the next step is to figure out what are those mechanisms or those components of self-injury that increase risk that can also be modified clinically. And to be able to look at that—and to further identify what features of self-injury give off those warning signs, so the more immediate signs that suicide risk is there—so that we can better, hopefully, detect possible risk early on and plan for it to reduce that risk.
And I think you had mentioned individuals with lived experience as well. I think probably one of the hardest things is being able to certainly ask for help, to ask for support, and to also monitor for yourself when the self-injury starts to feel out of your control. Because when I was working clinically, I had individuals who would get to the point where they started to talk about the self-injury starting to take control of them, versus them controlling the self-injury. And when they started to feel a loss of control over their self-injury, sometimes that's when the suicide risk would elevate. And so when I'm thinking just in the, from the framework of watching for suicide risk, for individuals with lived experience—and especially those who may still currently be self-injuring—I think it's being honest with yourself and watching for those signs that things maybe are not getting better, or that you're starting to see more frequent thoughts of suicide. Or maybe for the first time, suddenly thoughts of suicide are coming up around the time periods or context of self-injury. And those are signs to say, “you know what? Let's, it's really important to step out and ask for some help” because clearly people are struggling. And we also know that there are people there to support you and that can help.
And I'm a firm believer that we're all here for a reason—and so I know it's a little cliche to say like, “you matter” but you do. Like there's a reason we're all here. And so I think for those who are still struggling with self-injury and maybe even having some suicidal thoughts, to hang onto and kind of find where you, you have that purpose and that meaning because we all have that. And so and we want people to be around.
Dr. Westers: What a hopeful ending to a tough topic, talking about self-injury and its relationship and differentiation from suicide. My hope is that those listening will be able to feel more comfortable in identifying the risks but also protective factors that can bring hope and be able to know how to better respond to those who self-injure. Thank you so much, Dr. Muehlenkamp, for contributing your expertise in your research and knowledge to this. I think it would be really helpful for those listening. Thank you for joining us.
Dr. Muehlenkamp: Yeah, well thank you for hosting these. This is fantastic.
Dr. Westers: We hope you enjoyed this episode of The Psychology of Self-Injury Podcast. It is not considered therapy or meant to be a replacement for therapy, so if you or someone you love is in crisis and needs to talk to someone, you can reach out to the crisis text line—a global, not-for-profit organization providing free mental health texting service through confidential crisis intervention by texting “home” to 741-741. If you found this podcast helpful, please subscribe, give us a rating, and tell your friends. For all things psychology, follow me on Instagram and Twitter @DocWesters. For all things self-injury, follow I Triple S on Facebook and Twitter @ITripleS. I'm Dr. Nicholas Westers, thank you for listening to The Psychology of Self-Injury.