Understanding and Recovering from Non-Suicidal Self-Injury (NSSI)

"While it is imperative that clinicians have knowledge and skill in understanding and responding to NSSI ... how clinicians relate to their client’s experiences with NSSI is worthy of examination."

104583 Assessing & Treating Non-Suicidal Self-Injury

Live Event

Tue, Jun 30th, 2026

8:00am – 11:15am US Pacific Time

3 CE Hours Evidence Based Interventions, DBT

This training provides mental health professionals with a comprehensive framework for assessing and treating non-suicidal self-injury (NSSI). Participants will learn to identify key risk factors and observable signs, developing the ability to recognize both subtle indicators and more overt behaviors.

The course emphasizes evidence-based approaches to conducting thorough and sensitive assessments, guiding clinicians through structured steps to determine whether an...

"I didn't want to die. I just wanted everything to stop for a little while."

The thoughts kept racing, the emotions felt too big to hold, and it seemed like no one could really understand what was happening inside. There was a constant sense of pressure building—sadness, anger, shame, anxiety, loneliness, or sometimes nothing at all except a painful numbness. It felt overwhelming, like carrying a weight that never let up.

In those moments, self-injury seemed like the only thing that could provide relief, even if only briefly.

The physical pain felt easier to manage than the emotional pain, and for a short time, the intense feelings quieted down. There might have been guilt afterward, promises to never do it again, and confusion about why it kept happening. Yet when the distress returned, the urge often returned too. The behavior was not about wanting to die; it was about trying to survive emotions that felt impossible to manage and finding a way, however unhealthy, to cope with pain that seemed unbearable.

Perspectives on Non-Suicidal Self-Injury

The above experience is often the reality for the millions of Americans who engage in Non-Suicidal Self-Injury, or NSSI. When pain and distress become too overwhelming, a person may turn to injuring themselves to find relief. Common forms of NSSI include cutting, scratching, burning, hitting oneself, interfering with wound healing, or other behaviors intended to cause physical injury without suicidal intent. Suicide and self-injury may sometimes have a relationship with each other, or they can be mutually exclusive. The Center for Suicide Prevention (CSP) offers the diagram below to enhance our understanding of the relationship between these two entities:

*Courtesy of the Center for Suicide Prevention*

People who engage in NSSI often feel a tremendous amount of shame regarding their self-injurious actions. They may hide wounds or scars, lie about visible injuries, and minimize their current distress to others. As Brene Brown says, “Shame thrives in secrecy”. This is often the case with NSSI, as the act of self-injury itself and the consequential aftereffects (i.e. needing medical attention, feeling guilt or distress at having hurt oneself) often lead individuals into a downward spiral. Rather than the self-injury providing sustained relief and comfort, the act can result in more discomfort and distress rather than less.

Marsha Linehan, the founder of Dialectical Behavior Therapy, or DBT, offers valuable insights into self-injury. DBT was initially created to target suicidal and self-injurious behaviors. Linehan’s perspective on non-suicidal self-injury (NSSI) is rooted in Dialectical Behavior Therapy (DBT) and the biosocial theory of emotion dysregulation. From this lens, NSSI is not viewed as attention-seeking or manipulation, but as a learned, short-term coping strategy that develops when a person lacks effective skills to manage intense emotional arousal, invalidating environments, and chronic distress. Linehan conceptualizes NSSI as serving clear functional purposes, most commonly:

Rapid reduction of overwhelming emotional arousal
Temporary interruption of dissociation or numbness
Self-punishment driven by shame or self-criticism
Communication of internal distress when words feel unavailable
Attempt to regain a sense of control during emotional chaos

Linehan’s model treats NSSI as:

Functionally understandable, even when clinically high-risk
Maintained through short-term relief (negative reinforcement)
Strengthened by emotion dysregulation + invalidating environments
Modifiable through skills training, not punishment or shame

A key DBT stance is the balance of:

Radical acceptance of the person’s pain and behavior history
Clear commitment to replacing the behavior with safer coping strategies

The Clinician’s Experience with NSSI

While it is imperative that clinicians have knowledge and skill in understanding and responding to NSSI, their own experiences working with clients who are struggling with NSSI is of paramount importance. Clinicians can easily become overwhelmed with the visual presentation of self-injury wounds or scars and may have their own lived experience with trauma or even self-injury themselves. Clinicians may also assume that a client who is self-injuring is suicidal, which, as discussed previously, is not always accurate. How clinicians relate to their client’s experiences with NSSI is worthy of examination. Consider these questions to explore your thoughts and feelings:

What emotions come up in me when working with clients who engage in NSSI, and how might those reactions shape my clinical responses?
How do my beliefs about the function of NSSI influence my level of curiosity, judgment, or empathy in session?
When I feel urgency to stop the behavior, how do I balance risk management with understanding the client’s emotional experience?

These questions are aimed at increasing therapist self-awareness in moments where NSSI is present in clinical work. Reactions like urgency, discomfort, or a strong desire to “fix” the behavior quickly are common, and they can subtly shift the work away from understanding toward problem-solving or risk management alone. When clinicians notice their own emotional responses, it becomes easier to stay grounded in curiosity rather than judgment.

Clinical Tools and Interventions

The NSSI Bill of Rights: A person-centered and empowering approach

As we explore the reality of shame felt associated with NSSI, incorporating a person-centered framework is essential in creating psychological safety for clients to feel validated and heard. One resource to accomplish this is the "NSSI Bill of Rights", which includes affirmations and principles meant to reduce shame and promote compassionate understanding of NSSI. It is a widely shared psychoeducational tool that emerged from DBT, trauma-informed care, and self-harm advocacy work. As you review the NSSI Bill of Rights below, consider any current clients experiencing self-harm that might benefit from introduction to these principles.

You have the right to:

Be treated with dignity and respect, regardless of your history of self-injury.
Have your experience taken seriously, without judgment, minimization, or panic.
Be listened to with curiosity and compassion when you talk about your pain.
Have your self-injury understood as a coping strategy, not a character flaw or manipulation.
Receive support that focuses on understanding the function of your behavior, not just stopping it.
Learn and access safer, more effective ways to cope with overwhelming emotions.
Move at a pace that feels emotionally tolerable in the process of change and recovery.
Have confidentiality respected within appropriate ethical and safety limits.
Be included in decisions about your treatment and care whenever possible.
Experience setbacks without being labeled as “noncompliant” or “difficult.”
Be free from punishment, shaming, or coercive responses related to self-injury.
Be seen as a whole person—not defined by self-injury or your symptoms.

These principles and affirmations can be an ideal starting point in clinical work, and many clients will feel more comfortable discussing their NSSI if they perceive that their therapist is affirmative – not of the self-injurious behavior itself, but of the rights and needs of clients to be respected, heard, and valued.

Assessment & Intervention Recommendations

As with most areas in mental health, thorough assessment and conceptualization of self-injury is imperative. Clinicians can incorporate formal screenings and informal questions into their assessment process. The SOARS model is a structured, semi-clinical framework often used in school, crisis, and outpatient settings to guide a focused assessment of non-suicidal self-injury (NSSI). It is designed to quickly organize clinical thinking around function, risk, and context while maintaining a nonjudgmental stance.

S – Self-injury behavior:
What is happening (methods, frequency, severity, recent episodes)?

O – Occurrence context:
What was going on right before it happened (triggers, situation, environment)?

A – Affect/cognition:
What emotions and thoughts were present before, during, and after?

R – Reinforcement/function:
What does the behavior do for the person (relief, regulation, escape, control)?

S – Safety/support:
Current suicide risk, access to means, protective factors, and supports?

Behavior Chain Analysis

Behavioral analysis of events leading up to, during, and after the self-harm event is essential. While the SOARS framework is a starting point for this, DBT offers another valuable tool in the form of behavior chain analysis. Imagine various links connected to form a chain – with a starting and end point. Chain analysis is helpful for NSSI because it breaks the behavior down into a step-by-step sequence, making it easier to understand what leads up to the urge, what happens during the episode, and what follows afterward. Instead of viewing self-injury as a single event, it highlights the vulnerability factors, triggers, thoughts, emotions, and environmental cues that contribute to it. This allows both clinician and client to identify specific points where alternative coping strategies could be introduced. Over time, it supports pattern recognition and skill-building, which is central to reducing reliance on the behavior. Here is an example which illustrates the process and experience of NSSI. The visual nature of the chain analysis template provides an externalized map for the therapist and client to review and discuss.

The CARESS Model

The CARESS model, developed by Lisa Ferentz, was designed to create self-sufficient, soothing strategies to create more meaning from an urge, rather than being told the individual cannot/is not allowed to engage in self-destructive behavior. This approach is intended to feel less restrictive and limiting. Engaging in the CARESS skill accomplishes what the self-destructive behaviors hope to achieve and also decreases the need to engage in these patterns over time. To see application of the CARESS Model demonstrated, here is a role play example.

Client: I had urges to self-harm again this week. It felt like everything was building and I didn’t know what else to do.

Therapist: I’m really glad you told me. Let’s slow it down and look at what might help in those moments. One tool we can practice is the CARESS model. It gives you several options before the urge takes over.

Client: I don’t know if anything else works when it gets that intense.

Therapist: That’s important to name. CARESS is about having multiple options. First, C—Communicate alternatively: instead of turning inward, you might text someone, write what you’re feeling, or even record a voice note to express it safely.

Client: Okay… maybe writing.

Therapist: Next is R—Release endorphins, like a brisk walk, cold water on your hands, or movement to shift the body’s stress response.

Client: I’ve tried walking before—it helped a little.

Therapist: Good data. Then E—Express emotions safely, like journaling or art, and S—Self-soothe, such as grounding, music, or holding something comforting. We can build a personalized CARESS plan so you’re not facing urges alone.

Concluding Recommendations

As observed in the above intervention examples, there is a significant focus on behavioral intervention and structured strategies to increase distress tolerance and decrease urges to act on self-harm thoughts.

As you continue to support clients engaging in NSSI, consider these recommendations:

Prioritize a calm, collaborative, nonjudgmental stance that reduces shame and strengthens therapeutic alliance, as rupture and invalidation can intensify NSSI risk.
Conduct ongoing, structured risk assessment (including frequency, function, triggers, and lethality) while distinguishing NSSI from suicidal intent without assuming either is static.
Use functional analysis/chain analysis to identify the emotion–cognition–context sequence maintaining the behavior and to locate intervention points.
Focus on emotion regulation and distress tolerance skill-building (e.g., CARESS, DBT skills) rather than relying solely on “stop self-harm” directives.
Develop a practical, individualized safety plan that includes coping alternatives, means safety strategies, and clear steps for escalating support during high-risk periods.
Validate the function of NSSI (e.g., emotion regulation, self-punishment, dissociation management) while gradually expanding alternative coping strategies that meet the same needs more safely. ◼