Looking at the brain processing of pain and emotional distress, and considering the neurodevelopmental changes happening in adolescence, may help clinicians better understand DSH.

Suicidality and DSH are both common and overlap; DSH is a marker of increased risk of future suicide attempts. Andover et al. studied DSH and suicidality among 117 psychiatric inpatients (Andover & Gibb, 2010). Two-thirds of the patients reported a history of suicide attempt(s) and 45 % reported a history of DSH, with cutting being the most common method. Patients with a history of DSH were more likely to report a history of attempted suicide, and frequency of DSH was correlated with the number of suicide attempts. Interestingly, after controlling for depressive symptoms, hopelessness, current suicidal ideation, and symptoms of BPD, a history of DSH still remained significantly correlated with a presence/absence of suicide attempts. Also, reported DSH frequency positively correlated with patient perceptions of lethality of suicide attempts.

Another study, by Nock et al., looked at the relationship between DSH and suicide attempts (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). Data was collected from 89 young adults who were admitted to a psychiatric inpatient unit and had engaged in DSH in the previous 12 months. DSH was associated with suicidality in patients with a longer history of DSH, multiple methods of DSH, and absence of physical pain during DSH.

Similar findings were noted by Whitlock, Muehlenkamp, and Eckenrode (2008). They surveyed college students with the goal of determining possible subtypes of DSH. Based on a survey of 2,101 students, those who reported 11 or more incidents of DSH using three or more forms of self-injury were the most likely to report suicidality. Also of note, almost half of the students with the most frequent and varied DSH reported that DSH was not/is not a problem in their life.

A study of 373 high school students looked for differences between adolescents that self-harm versus those who have a history of both DSH and suicidality (Brausch & Gutierrez, 2010). Students were divided into three groups: no history of DSH, a history of DSH but no suicide attempts, and history of both DSH and suicide attempts. Unsurprisingly, the no-self-harm group reported the lowest level of hopelessness and highest levels of self-esteem. Comparing the two groups with a history of DSH, the no-suicide-attempts group reported lower depression scores, less suicidal ideation, greater parental support, and greater self-esteem than the suicide-plus-DSH group.

A thorough assessment of DSH behavior is imperative in guiding care and treatment approaches. There are multiple formal assessment tools available including questionnaires such as the Functional Assessment of Self-Mutilation, the Self-Harm Behavior Questionnaire, the Inventory of Statements About Self-Injury, and formal interview tools such as the Self-Injurious Thoughts and Behaviors Interview, and the Suicide Attempt Self-Injury Interview (Gutierrez, Osmann, Barrios, & Kopper, 2001; Klonsky & Glenn, 2009; Linehan, Comtois, Brown, Heard, & Wagner, 2006; Lloyd-Richardson et al., 2007; Nock, Elizabeth, Photos, & Michel, 2007). These tools were largely developed for research purposes and, though not widely used in the clinical setting, can be used clinically and provide guidance on the important elements of a detailed assessment. Below is advice for the initial approach to DSH and an overview of important areas to cover in assessing the behavior.

The initial reaction of a care provider is important. Reactions of shock, disgust, or other intense negative judgments make it less likely that the person engaging in DSH will bring up the behavior in the future and be forthcoming with further details about the behavior. It is recommended that caregivers respond in a low-key, respectful manner (Walsh, 2007). Initial questions such as “What does self-injury do for you?” can help to communicate that you are interested and wanting to gain a better understanding. Attempts to forbid the behavior or quickly “contract for safety” are not helpful. It is not realistic to think that a person who has developed a coping technique can quickly abandon it, without time to work on establishing other coping skills. So the goal will be to establish a long-term therapeutic relationship, in which DSH can be assessed over time and other coping skills can be learned.

Important areas of assessment include a detailed history of DSH, information about recent DSH behaviors, functions of DSH, triggers and consequences of DSH, and screening for suicidality. When taking a detailed history of DSH, it is helpful to explore the age of onset of the behavior, types of injuries, and frequency of DSH, along with the number of wounds typically inflicted, location of the wounds, experience of pain, and the severity of tissue damage. A longer duration of DSH generally portends a more challenging path to alleviating the behavior. And as discussed above, in at least one sample of young adults, greater risk of suicide attempts was associated with a longer history of DSH, use of a greater number of methods, and the absence of physical pain during DSH (Nock et al., 2006).

In gathering information about DSH occurring in the last couple of months, assessing the function of DSH for the individual will be helpful in guiding treatment. Details about the recent frequency of DSH, number of wounds, and the level of tissue damage can help to indicate current level of distress. Also keep in mind that it is rare for individuals to inflict tissue damage requiring stitches or other medical intervention, and that individuals inflicting severe tissue damage may require emergency mental health assessment. Looking at the wounds, with an individual’s permission, may provide more objective information than a verbal description. If the DSH involves carved words, exploring the selection of the particular words can be helpful therapeutically. The location of injury is also important, as most people will injure extremities or the abdomen. Reports of DSH to the eyes, face, genitals, or breasts are red flags for psychotic or trauma-related behavior (Walsh, 2007).

Many aspects of timing can be helpful to clarify. The duration of time it takes for completion of the injury points to the length of time it takes to relieve distress; therefore longer periods of DSH may be more concerning. Also exploring the time of day of DSH may help in the development of replacement activities or changing usual routines to decrease DSH. Keeping track of the longest time period between DSH can be motivating for some patients, helping them push themselves to achieve longer and longer DSH-free periods. Other key pieces of information to obtain about recent DSH includes where the behavior usually occurs (e.g., bedroom, bathroom), if tools (e.g., nails, razorblades) are used, and whether DSH occurs alone or in the presence of others (may be virtual presence via online chat groups or social networking sites). All of these details are important when trying to work on altering habits and routines to work toward behavior change.

Examining details about the triggers which precede DSH behavior can help to predict the situations in which future DSH will happen. This allows individuals and care provider to recognize specific opportunities to practice other coping/replacement techniques and can guide attempts to interrupt the chain of thoughts and actions that lead up to DSH. These triggers can be environmental, such as discord in relationship or poor performance in school. Some triggers may be biological factors, such as sleep deprivation, illness, or intoxication. Other triggers are psychological in nature, thought and behavior patterns, affective states, and beliefs. The Suicide Attempt Self-Injury Interview provides a detailed assessment of possible triggers, focusing mainly on environmental triggers, and could be useful as part of a clinical evaluation (Linehan et al., 2006).

In addition, information about the consequences of DSH can help guide treatment. Similar to the assessment of triggers, environmental, biological, and psychological consequences should be examined. An important environmental consequence is the reaction of others to DSH. If the reaction of others reinforces the behavior, it may make sense to try to change that response. Biological consequences include the degree of physical pain experienced, and whether actions are taken to promote wound healing. Important psychological consequences are an individual’s emotional state after DSH, their thoughts regarding the DSH (shame, guilt, pride), and the sequence of behaviors afterward. These details may help to inform treatment approaches, for example, working on self-soothing techniques might be helpful for a patient who experiences relief from anxiety and a calm sensation after DSH, but may be less effective for a patient who feels invigorated and energized after DSH.

Though the intent of DSH in most individuals is not suicide, it is very important for care providers to monitor on an ongoing basis suicidal thinking, plans, and attempts, as many of the psychological characteristics of individuals engaging in DSH put them at a high risk of suicide (Nafisi & Stanley, 2007).

Treating self-injuring patients can be challenging, as it is usually a slow process of change, and patients using DSH as a coping mechanism often have difficult personality characteristics. These are often patients that are surrounded by negative judgments, from their families, friends, society, and most importantly, themselves. Even after gaining insight into the reasons for their DSH behaviors, individuals may find it very difficult to change. Some of the methods for maintaining a therapeutic relationship with individuals with DSH behaviors are reviewed here, followed by identification of specific therapies that have demonstrated effectiveness in treating DSH (Gratz, 2007; Klonsky et al., 2003).

One important aspect of care is validation of the patients’ feelings through listening, reflecting, and understanding. Acknowledging that a patient’s emotional pain is real and that you understand DSH provides relief helps a patient feel validated and can facilitate further work on the DSH behavior. This should be validating the effect, not validating DSH as the best means. Also important is for a care provider to firmly support patient self-care and the cessation of DSH behavior. Eliciting the patient’s thoughts about the negative consequences of DSH may be helpful as many people are distressed by the behavior. Being able to present additional concerns if patients are unable to come up with adverse consequences can also help to facilitate contemplation about cessation of DSH. Provider concerns might include that DSH can result in infection, pain, and unintentional severe injury or death. It can lead to social embarrassment and shame because it is not a socially acceptable behavior, and most importantly it does not resolve the patient’s underlying problems. DSH ends up being a cycle of destructive behavior, which the patient relies upon instead of developing healthier coping strategies.

A pitfall to avoid is that overconcern and effusive compassion in response to DSH may inadvertently reinforce the behavior. On the other hand, DSH often elicits strong negative emotions in care providers, causing providers to reprimand patients, ignore or minimize the DSH behavior, or withdraw from the alliance. The most effective approach is to maintain a dispassionate, nonjudgmental demeanor in discussing DSH. It also may be useful when experiencing intense frustration and negative judgments about an individual with DSH to remember that the behavior is functional instead of labeling the individual as manipulative.

In managing the frustration that can occur during the slow course of treatment, it is important to have realistic expectations—that patients with DSH may take longer to progress with therapy than other patient populations, that there will be relapses of the behavior, that you will need to pay close attention to detect small improvements, and that it is common for patients with DSH to resist the introduction of other coping mechanisms either verbally or through noncompliance. Getting support and outside perspective from colleagues to avoid burnout can also be very useful.

Many types of treatment have been utilized for DSH. Please see Table 2 for a summary of the level of evidence for some of the recognized interventions (Karr, Muehlenkamp, & Turner, 2010). Below is a review of pharmacotherapy and cognitive-behavioral and psychodynamic therapy interventions.