1. Non-suicidal self-injury (NSSI)
A Resource for Teachers

2. Defining non-suicidal self-injury (NSSI)
Deliberate self-inflicted injury to one’s own body tissues without conscious intent to die
Not considered a socially approved practice within one’s culture
Excludes ear piercing, tattooing, circumcision, or cultural healing rituals
NSSI is also referred to as self-harm, it is the deliberate and direct destruction of one’s body tissue without suicidal intent and not for body modification purposes.
NSSI does not include tattooing or piercing, or indirect injury such as substance abuse and eating disorders. Also, this type of self-injury is different  than “self-injurious behaviors” (SIB)  which  are commonly seen among individuals with intellectual and developmental disabilities.

3. Prevalence rates
15% to 20% of middle and high school students engage in NSSIB
Prevalence rates are much higher in clinical samples of adolescents (between 12-65%)
Typical age of onset occurs during middle school, roughly between the ages of 12 to 15 years
In adolescent samples, females are more likely to report having self-injured but by late adolescence, young males and females report similar rates
The most commonly found risk factors for NSSI is having difficulties with regulating emotions
Between 14 to 24% of youth and young adults in the community report engaging in self-injury  at least once in their life. Some studies have found even higher percentages if they provide comprehensive checklists of the different types of possible self-injury methods or if they advertise their study as one about self-injury. 
Self-injury can start at any age, but most people who self-injure start when they are teenagers. Many people who start self-injuring in their teens continue into adulthood, while others may start self-injuring as adults. Although any one at any age may begin to engage in self-injury, research shows that the most common  age of onset for self-injury is  early adolescence.

4. Common forms of NSSI scraping or scratching skin
cutting skin
self-hitting or banging (to break or bruise)
burning
pinching
interfering with a healing wound
self-biting
picking or ripping skin
The most common methods of self-injury include cutting, burning, scratching, and bruising. These injuries can range in severity from minor to moderate. 
The seriousness of a person’s distress is NOT related to the severity of the self-injury. Research has shown that self-injury is related to emotional difficulties, distress and sometimes suicidal feelings.  Therefore, any degree of self-injury needs to be taken seriously.

5. NSSI vs. Suicidal Behaviour
Non-suicidal self-injury
Suicidal behaviour
Intent
To get immediate relief from negative emotions
To die in order to permanently escape emotional pain
Repetition
More frequent
Less frequent
Lethality
Often involves less lethal methods but with a potential for lethality
Tends to involve more lethal methods
Psychological consequences
Often used to relieve psychological pain
Often aggravates psychological pain
Gender
May or may not occur often in women, depending on sample
Occurs more often in women but men are more likely to die by suicide
Non-suicidal self-injury is not a suicide attempt because it is done as an effort to feel better, not to end life -  dying is not the goal of self-injury.
Most people who self-injure say they do it to feel better, to express their pain and/or to stop feeling numb. In fact, some people who self-injure even say they do it to stop themselves from acting on urges and thoughts to kill themselves. Although self-injury and suicide attempts are different behaviors, many individuals who self-injure also may struggle at times with suicidal feelings. 

6. Why do people engage in NSSI?
To reduce negative emotions and thoughts
NSSI involves the body’s natural pain killers. This can result in the release of pleasant feelings
To stop themselves from acting on suicidal thoughts and urges
To punish one-self
To reconnect with one-self and others
NSSI is complex and is often the result of many converging factors. The explanations are equally complex.
People who self-injure have a hard time dealing with their feelings. Instead of being able to cope with an intense emotion (such as sadness or anger), they use self-injury to reduce, manage, or escape from these feelings. Because for some people the self-injury brings relief, it is tempting to keep using it to cope with these difficult feelings. However, the more often individuals use self-injury to cope, the more likely they are to self-injure when they have difficult feelings in the future. Many people who self-injure report feeling that they “can’t stop” or that they “are addicted” to self-injury. It is important to break the cycle early on as it becomes increasingly difficult to stop.
However, some people who self-injure also experience depression. People who are depressed have a lot of negative thoughts (about themselves, others, the world around them, and their future), they may feel hopeless and as if they are a burden to others. These feelings CAN lead to suicidal thoughts and actions. Sometimes people may self-injure as a way to cope, and to stop themselves from acting on these thoughts and urges of suicide.
In any case, because we know that those who self-injure are also at greater risk for attempting suicide at some point (even though these are different behaviors), anyone who self-injures should be screened by an ASIST trained staff for possible suicide risk.
Sometimes people self-injure to punish themselves for things they feel guilty about, or when they are really hard on themselves and feel they have not done well enough.
Some people self-injure to reconnect with themselves and others (that is, to feel something, even if it is pain). Some people use self-injury as a way to tell others about how they feel.
There are many other reasons for self-injuring and someone may self-injure for more than just one reason or the reason for the self-injury may change over time as the self-injury continues. As anyone who self-injures will tell you, it is very hard to say “why” they self-injure, it is a complex combination of things - however they do know that they are doing this to try to feel better in one way or another.

7. How can School Personnel help at the time of disclosure?
Do:
Respond in a calm and caring manner.
Don't be afraid to state, "I've noticed injuries that appear to be self-inflicted, I care about why you might be doing that" or, "it appears you have hurt yourself, do you want to talk about it?”
Understand that this is the student’s way of coping with pain.
Have a non-judgemental compassion for the student’s experience.
Offer to be a caring adult for the student while they are seeking mental health support.
Acknowledge their feelings; offer to listen, be available.
Encourage participation in extracurricular activities and outreach in the community (e.g. volunteering with animals, nursing homes, tutoring or mentoring).
Discover the student’s strengths.
Initial responses to disclosure play a critical role in adolescents’ future help-seeking behaviour. It is common for school personnel to have negative attitudes towards NSSI and experience horror, repulsion, fear, sadness and helplessness. However, it is important that school personnel continue to monitor themselves to ensure that negative reactions are not being expressed if a student discloses NSSI. Additionally, it is important for school personnel to refer to informed colleagues should they feel uncomfortable or not fully informed about the behaviour.

8. How can School Personnel help at the time of disclosure?
Don’t
Be overly reactive as this could alienate the student and damage the developing alliance.
Show excessive interest in the NSSI behavior.
Permit the student to relive the experiences of NSSI in detail, as this can be triggering.
Try to stop the behaviour with threats or ultimatums.
Discourage self‐injury; threaten hospitalization, use punishment or negative consequences.
Act shocked, overreact, say or do anything to cause guilt or shame.
Publicly humiliate the student .
Talk about the student’s NSSI in front of class or peers.
Agree to hold NSSI behaviour confidential.
Make deals or promises you can’t keep in an effort to stop NSSI.
It is essential for school personnel to monitor themselves to ensure they respond in a calm, respectful, and helpful way if a student discloses NSSI. This may be the student’s only disclosure, making it an important one.

9. School response protocol
Wounds are severe or life-threatening or the student is attempting suicide
Wounds are not life-threatening
Report all concerns related NSSI to the school principal or designate.
A suicide risk review will be conducted by an ASIST trained staff
The ASIST trained staff and principal or designate, will identify the level of NSSI risk
Provide first aid and assess lethality of injury
Send someone to call 911 and to communicate with the principal or designate.
Listen empathically and carefully to the student’s message.
The principal or designate will call the parent(s) or guardian(s).
The referral process can be difficult for both students and school personnel. A student may have approached you in confidence as someone who he or she trusts and may be resistant to sharing his/her NSSI with others. Let the student know that you care about him or her, and are concerned about his/her welfare, and that you want to help him/her get support.
Accompany the student to meet with the principal or ASIST trained staff. If the student would like, stay with him or her during this meeting. It may be easier for some students if you relate the NSSI in the student’s presence; this helps to set the tone of the dialogue, and allows a hesitant student the opportunity to enter more gradually into this process. Offer this option if the student is not ready to speak on his or her own behalf, but make sure that you check in with the student during the meeting to ensure that you are getting his/her story right and to see if he/ she would like to add or clarify details.
Should the student be identified as potentially suicidal, DSB Ontario North East Youth Suicide Prevention, Intervention and Response Protocols are followed.

10. DSB Ontario North East Protocol Flowchart
Staff suspects NSSI
Student shows signs and symptoms of NSSI
School staff becomes aware of student NSSI
Contact the Principal or Designate
ASIST trained staff conducts suicide review and consults with the principal or designate
NSSI - Low Risk
* Not suicidal
* Self-injury is superficial
* No co-occurring mental health
issues or only mild mental
health problems.
* Encourage student to call
parent(s)/guardian(s)
* If child is under the age of 12, call
* Refer student to Mental Health
Team and/or external services
* Follow up 2 weeks later
NSSI - Moderate of High Risk
* Any associated risk of suicide
* Severity of self-injury is high
* Co-occuring mental health issues
or related conditions
* Call parent(s)/guardian(s)
* Encourage parent(s)/guardian(s) to
call their family physician, NEOFACS
Intake for Mobile Crisis Response
or another
emergency mental health facility
Provide first aid and assess lethality
Self-disclosure of NSSI
Peer disclosure of NSSI
DSB Ontario North East Protocol Flowchart
If the student is suicidal, follow suicide protocols
(see:
To facilitate a smooth transition from the time of identification to referral and ongoing support, refer to our protocol to outline a standard response to self-injury:

11. Confidentiality
Be cautious about telling the student that you won’t tell anyone about their self-injury. There could be
a risk of suicide
a health risk
a self-injuring group of peers, and/or
As per our protocol, staff shall report all concerns related to potential self-harm to the school principal, vice-principal or designate:
The safety and well-being of all students are our primary consideration and responses to NSSI should be considered a priority. Although NSSI and suicide are distinct, every student who is identified as engaging in NSSI should be screened for suicide risk by an ASIST trained staff. If there is any associated suicide risk, the student should be referred to emergency mental health services.

12. Circles of vulnerability for contagion of NSSI
Geographical proximity
Psychological proximity
Social proximity
Population at risk
While you can’t “catch” self-injury, knowing someone who self-injures can increase the chance that someone will self-injure if he/she already has difficulty coping with difficult emotions.
Self-injury is usually done in private and differs from person to person (in terms of how, where, and why it is done). People only self-injure when the self-injury fills a need for that person. People who already use healthy ways to cope with distress and difficult emotions are unlikely to start self-injuring after learning that someone else self-injures. People who find it hard to cope with difficult feelings may be more likely to try out unhealthy ways of coping (such as self-injury) after learning that a friend does it.

13. Contagion in Schools Schools
Trends have been suggested whereby multiple students who self-injure, communicate frequently about NSSI, and trigger the behaviour in each other.
Youth may self-injure in front of each other, share the same tools, implement or take turns injuring the body parts of others in the group.
Some adolescents will pick up self-injuring behaviour from siblings or peer group leaders.
The Internet introduces an additional challenge. Online anonymity may help manage shame, isolation and distress. Virtual interactions can provide community, intimacy and honesty that may be lacking in real life. Hence, shared triggers, techniques and attitudes may influence choices outside the virtual community.
Showing NSSI on YouTube represents a new trend. NSSI on YouTube may normalize the behaviour, which may trigger and reinforce NSSI behaviour. Professionals working with youth need to be aware of the scope and nature of NSSI YouTube videos.

14. Managing contagion in the school
When discussing NSSI with students, the following guidelines will help in preventing contagion:
Do not allow students to share detailed information regarding NSSI, reveal their scars, or share NSSI related images or stories.
Do not use school-wide assemblies, newsletters, school newspapers to address an “outbreak” of NSSI.
Do not present media that glamorize NSSI [as part of classroom curriculum].
When educating youth about NSSI, discuss the behavior in its broader context; that is, as a maladaptive coping strategy among several others (such as substance abuse, or risk-taking).
Emphasize the need for students who are engaging in the behavior to seek support.
To minimize the risk of social contagion
Identify those at risk.
Seek assistance when necessary.
Link individuals to resources.

15. THANK YOU! We hope that you found this a useful introduction to NSSI.
For more information, please refer to pp. 121 – 125 of Supporting Minds: An Educator’s Guide to Promoting Students’ Mental Health and Well-being:
Should you have questions,
your Mental Health Leader is available
to provide ongoing support and
leadership to your team.