A person-centred conceptualisation of non-suicidal self-injury recovery: a practical guide

ABSTRACT

Background

Non-suicidal self-injury (NSSI) is a behaviour many counselling psychologists encounter in practice, and the way clinician’s respond can have an important impact on the individual’s experience of recovery. The person-centred NSSI recovery framework incorporates the voices of lived experience in understanding the multi-faceted nature of recovery.

Objectives

This paper outlines important considerations for how the recovery framework can guide clinicians with respect to both therapeutic stance and intervention targets in order to support clients in navigating their experience of NSSI and recovery.

Implications

Clinicians should adopt a strengths-based approach and foster self-efficacy and self-compassion with persons with lived experience. This paper provides specific recommendations for counselling psychologists and their clients, including encouraging clinicians to avoid making assumptions about the causes, meanings, and outcomes of self-injury, and to be cognizant of the non-linear nature of the recovery process.

KEYWORDS:

• NSSI
• self-injury
• recovery
• person-centred
• strengths-based

Over the past 20 years, non-suicidal self-injury (NSSI) has increasingly been recognised as a critical mental health concern. Defined as the purposeful damage to one’s body tissue (e.g. cutting, burning), NSSI is common, with international figures showing approximately 18% of youth and 13% of emerging adults in non-clinical settings report past engagement in the behaviour; among university students, rates are about 20% (Swannell, Martin, Page, Hasking, & St John, 2014). Rates of self-injury in clinical samples are much higher – up to 66% (Hauber, Boon, & Vermeiren, 2019). While these age groups report NSSI most often, it is nevertheless common across the lifespan, with about 6–8% of pre-adolescents aged 8 to 12 (Barrocas, Hankin, Young, & Abela, 2012) and 5–6% of adults reporting prior NSSI (Klonsky, 2011; Swannell, Martin, Page, Hasking, & St John, 2014). People report an array of reasons for NSSI; typically, however, NSSI is most often used as a means to obtain short-term relief from difficult emotional experiences (see Taylor et al., 2018). As such, it should come as no surprise that people with lived experience of NSSI report a range of mental health difficulties (e.g. high distress, difficulty coping) and often, though not always, experience concomitant mental illness (e.g. major depression, eating disorders, borderline personality disorder; Hooley & Franklin, 2018; Washburn & Washburn, 2019). Of high concern is research indicating that NSSI confers risk for suicide (Kiekens et al., 2018; Klonsky, May, & Glenn, 2013). Notably, NSSI has been identified as the most reliable predictor of later suicidal behaviour (Franklin et al., 2017).

Following the above, there have been increasing efforts to prioritise lived experience in discussions about how we understand NSSI. Hearing from individuals with lived experience allows us to better understand the functions and meanings ascribed to self-injury from both individual and social approaches (Lewis & Hasking, 2023; Steggals, Lawler, & Graham, 2020, and can inform clinical practice. In this regard, a recent and burgeoning line of inquiry has sought to understand NSSI recovery (e.g. Kelada, Hasking, Melvin, Whitlock, & Baetens, 2018; Lewis, Kenny, Whitfield, & Gomez, 2019; Meheli & Lewis, 2022). Efforts in this regard have underscored the value in adopting a person-centred framework that accounts for the complexities and nuances of people’s lived experience (see Lewis & Hasking, 2020, 2021b). To date, however, most published work in this space is empirically and conceptually grounded. Although useful, much less attention has centred on how this framing of NSSI recovery can be translated into clinical practice. Indeed, there is, as of yet, no comprehensive research-informed practical guidance rooted in this framework for counselling psychologists to draw on when working with clients who self-injure. As such, the aim of the current paper is to provide applied strategies across framework components that can be implemented when working with individuals with lived experience of NSSI. Commensurate with recent shifts in the field and our understanding of recovery (e.g. Lewis & Hasking, 2021a, 2021b), the approaches discussed move beyond cessation of the behaviour to embody a more holistic, person-centred approach to NSSI recovery.

A person-centred conceptualisation of NSSI recovery

Building on a series of studies bringing voice to people’s lived experience of NSSI recovery (e.g. Kelada, Hasking, Melvin, Whitlock, & Baetens, 2018; Lewis, Kenny, Whitfield, & Gomez, 2019; Lewis & Hasking 2021a, 2023), we developed a person-centred framework, which articulates the multi-faceted nature of recovery (BLINDED FOR REVIEW). This person-centred approach recognises that each individual is unique, and centres the individual as an expert in their own experience. We do not suggest the framework is a guide for person-centred therapy as conceptualised by Rogers (1951), but use the term to prioritise the individual in the recovery process, giving voice to their unique experiences. Given this, we do not intend to suggest this framework will apply to all individuals who self-injure, however it does include components that individuals have told us are germane to their recovery experiences. In particular, the framework comprises the following components:

• Realistic Expectations and Setbacks: Recognition that recovery is a non-linear and often ongoing process during which setbacks (e.g. NSSI recurrences) are expected and normal.

• Normalising Thoughts and Urges: Acknowledging that NSSI thoughts and urges are a normal part of recovery and may never fully go away (though will lessen in frequency and intensity over time).

• Fostering Self-efficacy: Promoting confidence in terms of people’s capacity to resist urges and find alternatives to NSSI.

• Identifying Strengths: Acknowledging that all people with lived experience of NSSI have strengths and that strengths can be cultivated over the course of recovery.

• Finding Alternatives: Identifying and using different ways of responding to NSSI urges that meet a similar need as NSSI, acknowledging this may take time and will vary across people.

• Addressing Underlying Adversities: Recognising that NSSI occurs in a context and not on its own. Thus, attention to and addressing factors contributing to NSSI and concurrent mental health difficulties/mental illness is imperative.

• Addressing and Accepting Scarring: Understanding that many people with lived experience will have permanent scarring from NSSI. As such, people will have diverse views when it comes to their scars. When concerns about scars (e.g. shame, anxiety, stigma) are salient, these need to be addressed in concert with promoting scar acceptance.

• Navigating Disclosures: Recognising that at different points (e.g. early in recovery, later in recovery), people may wish to share their NSSI with others in their life. Support may be needed to help individuals navigate this decision process.

• Self-acceptance and Self-compassion: By addressing the components that are relevant to a given person, people have capacity to find acceptance of who they are and to relate to themselves in a more compassionate manner.

• Resilience and Meaning-making: Through the above, individuals with lived experience can foster resilience that can extend beyond NSSI and in doing so, find meaning in their lives.

Within this framework, recovery ought to be viewed as unique for all individuals. Indeed, no two experiences of NSSI are identical and the same applies to its recovery. In keeping with its person-centred emphasis, the framework is also flexible in that its components apply differently across different people (i.e. some components may not apply to some individuals whereas for others all apply); and, even when an aspect of the framework is germane to people’s experience, this can still vary in its degree of importance (e.g. people may vary in the degree to which they have scarring and thus will differ in terms of how they view them). In addition, recovery is not conceptualised as an incremental, straightforward process. On the contrary, and as articulated by people with lived experience, recovery is a complex, non-linear, and very often ongoing process (see Lewis, Kenny, Whitfield, & Gomez, 2019). As such, we do not assume that there is a finite endpoint in the recovery process, nor do we see that recovery should adhere to a particular timeline. Further, although recovery naturally comprises behavioural cessation, it is a multifactorial process and thus involves an array of considerations beyond NSSI itself. Finally, a main pillar of the framework is the view that all people with lived experience of NSSI possess strengths and thus have the inherent capacity to develop inner fortitude and resilience over the course of their own recovery, thereby finding meaning along the way.

While theoretically sound, and built on lived experience voices, we recognise that application of this framework necessitates some practical guidelines for counselling psychologists. In the remainder of this paper we endeavour to do just that. We recognise that clinicians vary widely in their clinical orientations, their preferred therapeutic techniques, and their understandings of NSSI. Here we offer guidelines that may be used to embrace each component of our framework, but we acknowledge these are not exhaustive, and others may have alternate ways of recognising each component in a person-centred way.

Applied strategies for implementing the framework in practice

How do we demonstrate a person-centred approach?

Individuals with a history of NSSI often fear (and sometimes experience) negative reactions when disclosing their NSSI experiences, including from mental health professionals (Park & Ammerman, 2020). As such, adopting a person-centred approach becomes particularly important in the process of establishing trust and rapport with a client. At the core of a person-centred approach is recognising that the experience(s) of NSSI, and recovery, is different for each individual. Conveying to a client that you are adopting a person-centred approach means communicating that your goal is to understand their unique experience, and to recognise the client as the expert in their own experience. We recommend adopting a low-key dispassionate demeanour, and a respectful curiosity about the client’s experience (Walsh, 2012) that is non-judgemental and does not make assumptions about the causes, functions, or outcomes of NSSI. For example, a client may express that they recently felt an urge to self-injure after being criticised at work. A clinician may respond with: I’m curious about that. How did you feel hearing this criticism? This can also be reflected in setting goals with the client that may or may not include cessation of NSSI. A clinician could start a conversation with: I understand that it is difficult for you to think about stopping self-injury right now. What are some other things you might like to work on? This conveys to the client that their feelings and needs are valid and opens the door to disclosing related concerns that may later lead to discussion about stopping or reducing self-injury. Regardless of whether the client identifies their self-injury as a treatment goal, clinicians should consider how the function/s of self-injury may be related to their formulation of the client’s presenting concerns and consequently, how this may be related to a treatment plan (Andover, Schatten, Holman, & Miller, 2020; Andover, Schatten, Morris, Holman, & Miller, 2017).

How do we establish realistic expectations?

Communicating that NSSI recovery is ongoing, non-linear, and unique to the individual will assist clients in recognising that there is no “right” path to NSSI recovery. For some individuals, they may be able to cease NSSI and implement alternative strategies with little effort. For others, it will take years of trying, facing setbacks and successes along the way. If someone sets a goal of ceasing self-injury, it can be disheartening if they do self-injure, and can provoke feelings of shame, disappointment, and worthlessness (Kelada, Hasking, Melvin, Whitlock, & Baetens, 2018). It may help in this context to work with clients to re-frame these lapses as single instances of self-injury (e.g. It’s been a really tough week and I hurt myself today. It doesn’t mean I’m back to square one, I just went a month without self-injury), rather than as a “relapse” or a “failure” to meet goals (e.g. I just self-injured, now I have to start recovery all over again!). A client may keep a list of reappraisals on them to remind them of what they have accomplished (see Table 1 for examples). By setting realistic expectations, and reappraising any instances of self-injury, a clinician can help a client stay motivated to achieve their goals, and minimise a sense of failure or discouragement that may come from a perceived lack of “success” (Beck, 2011).

Table 1. Practical strategies that can used to support NSSI recovery from a person-centred perspective.

Component	Description	Example
Adopt a person centred approach	Everyone’s experience of NSSI is unique; avoid making assumptions about the causes, functions, or outcomes of NSSI Adopt a low-key dispassionate demeanour, and respectful curiosity	Can you tell me what NSSI means to you? Can you help me understand how you feel after you self-injure?
Establish realistic expectations	NSSI recovery is an on-going, non-linear, and unique experience. There will naturally be ebbs and flows in this process Reappraise instances of self-injury	I had a really bad week this week; it’s not surprising I self-injured. There have been many occasions I did not self-injure This is just one slip up. I am still learning how to cope and it will take time.
Normalise thoughts and urges	It is common for individuals to experience ongoing thoughts of self-injury Accept ambivalence	Conduct a decisional balance
Foster self-efficacy	Self-efficacy can take many forms, including self-efficacy to resist urges to self-injure and self-efficacy to engage in other strategies	Acknowledge, validate, and cheerlead small gains and times when a client has not self-injured What was different then that we can learn from? Are there time it is easier to resist urges to self-injure?
Identify strengths	All individuals possess strengths across a range of domains	Identify and encourage strengths with clients Values in Action
Find alternatives	Alternatives to self-injury can be implemented before an urge to self-injure arises, during an urge, or as an alternative way to	Stay healthy and raise emotional awareness Urge surfing and reappraisal Work with clients to develop support plans
Address underlying adversities	NSSI occurs in a context.	Explore adversities or associated concerns that may underpin NSSI Conduct a full assessment Set goals that may or may not include addressing NSSI
Foster acceptance of scarring	Many (not all) individuals who self-injure have permanent scarring Scars can mean different things to different people.	Work with clients to foster a sense of acceptance of scars Individuals are not defined by their scars
Navigate disclosures	Disclosures can be voluntary or involuntary, in person, or online. Work with the client to identify factors that are important to consider in disclosing NSSI	What do you hope to gain from disclosure? What effect do you think this will have (positive/negative/neutral)? How do you think the other person will react to the disclosure?
Generate self-acceptance	Self-acceptance is related to self-compassion; viewing oneself without judgment	Help the client to foster a sense of acceptance of themselves; in whole, including the “good” and the “bad”
Build resilience and find meaning	Finding meaning and a sense of purpose in life removes focus from NSSI	Work with the client to find purpose and belonging in their lives. Take time to savour the small moments and to celebrate when goals are met

For the individual who identifies ceasing their self-injury as a treatment goal, it can be helpful early-on to set an expectation that behaviour change is not linear. Clinicians could do this by prompting the client to think of a time they successfully changed another behaviour (e.g. something work or study-related) and to identify times when a lapse or temporary setback provided an opportunity for learning.

How do we normalise ongoing thoughts or urges to self-injure?

When we ask people what recovery would look like to them, it is not uncommon for individuals to respond with: When I no longer think about it or When I no longer have the urge to self-injure. And yet, many people continue to have thoughts or urges to self-injure, long after they have stopped self-injuring. Further, many people experience significant ambivalence about stopping NSSI – simultaneously wanting to limit the negative consequences of NSSI, but reluctant to give up a strategy that has helped them cope (Gray, Hasking, & Boyes, 2021). Normalising these ongoing thoughts and recognising a client’s ambivalence, validates their experience and sets up realistic expectations about recovery.

Within the context of a motivational interviewing framework, a clinician could use a decisional balance to help highlight any ambivalence a client may feel about changing their behaviour around NSSI. This can also help normalise thoughts and urges by recognising that ongoing thoughts may be reinforcing ambivalence about self-injury. In weighing up: the benefits of ceasing NSSI, the costs of ceasing NSSI, the benefits of not stopping NSSI, and the costs of not stopping NSSI, a clinician and client can work together to highlight where any ambivalence lies, and identify any barriers to behaviour change. While a decision balance is useful to highlight ambivalence, it must also be used judiciously. Of note, it may not be helpful to a client’s goals to focus too much on the benefits of NSSI. For this reason, a decisional balance is best used to either highlight ambivalence when behaviour change is not the goal, or as a way of initiating a conversation about change in a motivational interview. One way to manage this balance may be to focus only on the benefits of stopping self-injury and the costs of not-stopping, rather than addressing all four aspects of the decision. A decisional balance can also be used to foster self-efficacy, especially as the balance tips from continuing to self-injure to stopping or reducing self-injury (Miller & Rose, 2015)

How do we foster self-efficacy?

While a general belief in our ability to engage in behaviours that meet our goals is a reliable predictor of well-being, task-specific self-efficacy is a far better predictor of volitional behaviour (Bandura, 1986). When it comes to self-injury there are two forms of self-efficacy that are particularly pertinent: 1. Self-efficacy to resist urges to self-injure and 2. Self-efficacy to engage in alternative behaviours.

Self-efficacy to resist urges to self-injure

In general, self-efficacy to resist self-injury is associated with less recent, and less frequent, self-injury (Dawkins, Hasking, Boyes, Greene, & Passchier, 2019; Hasking & Rose, 2016). A recent line of research has reliably demonstrated that a belief in one’s ability to resist self-injury can vary across situations which are typically considered high risk (e.g. When I feel worthless), those that are considered protective (e.g. When I feel connected to my body) and when an individual is reminded of self-injury (e.g. When I see images of self-injury; Dawkins, Hasking, & Boyes, 2022). Further, self-efficacy in each of these contexts has been shown to correlate with self-efficacy to avoid suicidal action, and self-efficacy to regulate emotion, as well as history and frequency of NSSI (Dawkins, Hasking, & Boyes, 2022).

So how do we foster self-efficacy in different contexts when ongoing thoughts and urges may be present? First, it is important to acknowledge and validate small gains. A client may not be able to resist urges in all situations but may find it easier in others. Instances in which urges were not acted on should be highlighted, even if the individual self-injures in another context. A clinician can explore with the client what was different when the individual was able to resist any urges. For example: What were they thinking at the time? What were they feeling? Who were they with? What time of day was it? Encouraging the client to visualise or recall the situation, paying special attention to thoughts, emotions, and behaviour, can help the clinician and client to identify what was different in this specific instance, to inform their understanding of factors that may increase or decrease the likelihood of resisting urges in the future. The clinician and client can then identify which factors can be fostered, and which may be more difficult to target – perhaps deciding to tackle the more difficult situations later in the recovery journey. Second, individuals can be prompted to reframe instances when they did act on the urge to self-injure. As noted above, reframing instances of self-injury as opportunities for learning so as not to foster a sense of “failure” can help a client remain motivated toward behaviour change (Table 1). This reframing, in concert with recognising and explicitly validating situations in which the urge was not acted on, can build an individual’s belief in their ability to resist future urges even in a situation that may otherwise be viewed as a setback. This is especially important as individuals who self-injure may have difficulty recognising these instances when they occur.

Self-efficacy to engage in alternative behaviours

Coping with unwanted emotions is difficult for everyone. No one wants to feel anxious, depressed, scared, or alone. For some people, having a chat with a friend, going to the gym, or taking a walk on the beach may help alleviate these negative feelings and restore a sense of calm or balance. For individuals with a history of self-injury, their self-injury often achieves these same aims, at least temporarily. Self-injury is a coping strategy that is generally free, accessible, and works quickly and effectively to alleviate distress, restore a connection with the body, and/or create a sense of calm (Taylor et al., 2018). Given the benefits of self-injury, some have asked why more people don’t self-injure (e.g. Hooley & Franklin, 2018). Hooley and Franklin (2018) note that for many individuals there are natural barriers to self-injury, including aversion to pain, a positive sense of self, and a lack of knowledge of self-injury. For individuals who self-injure these barriers are often absent or diminished, making self-injury a feasible coping strategy.

Given this, it can be difficult to find new strategies that meet the same needs as quickly and effectively. Yet it is possible. It is helpful to frame these strategies as a set of techniques that may be used together to successively reduce arousal, so as to manage the expectation that a single alternative may reduce a 10/10 state of arousal; rather, an individual may use a range of techniques to iteratively reduce this state (e.g. from a 10, to an 8, to a 5… etc). Approaching new techniques with a sense of trial-and-error will reduce some of the pressure to “get it right”, recognising that different things work for different people, at different times, in different settings. It may be helpful to work with the client to develop a toolkit of techniques that can be used in different situations, and for different emotional intensities. Strategies that have worked before will be easiest to employ, and implementing them will help build self-efficacy in one’s ability to do so again. Implementing different strategies takes practice and takes time. An individual will not always feel capable of using new coping strategies when self-injury has worked so effectively for them in the past. Nevertheless, taking small steps as well as acknowledging and cheerleading gains may foster a sense of optimism and capacity to learn new skills.

How do we identify strengths?

Principle to our person-centred approach to framing recovery is the departure from deficits- to strengths-based considerations (BLINDED FOR REVIEW). Accordingly, strengths ought to be targeted, championed, and harnessed as assets throughout the entirety of a client’s recovery experience. In doing so, practitioners will be better positioned to help clients build their own resilience and thus navigate their own recovery journey. An initial step in this regard is working with clients to identify – and later turn to – their own strengths. To facilitate this, it is important to adopt a broad view of what strengths may entail. For example, strengths can be the resources someone draws upon during moments of distress (e.g. relationships and support networks, particular coping strategies), a willingness to talk about NSSI (which is inherently difficult for many people), held beliefs (e.g. a sense of efficacy) or values (e.g. a sense of meaning and purpose, a short or long-term goal), or various character strengths (e.g. wisdom, courage; Peterson, Ruch, Beermann, Park, & Seligman, 2007). Consistent with the core tenets of our framework, strengths are diverse and will thus vary across people and over time (e.g. one’s willingness to initially discuss NSSI with a clinician may translate to sharing NSSI with others in their lives) (see Lewis & Hasking 2021a, 2023).

A potentially helpful way to approach the identification of clients’ strengths is to draw on positive psychology given its emphasis on people’s positive attributes and characteristics. Of note, evidence suggests that individuals have a variety of strengths that are subsumed under a set of broader core virtues, namely: wisdom and knowledge, courage, humanity, justice, temperance, and transcendence (see Peterson & Seligman, 2004). To help clients identify which of these are present in themselves, it can be fruitful to present a list of strengths and ask them to rank them based on their personal relevance. The Values in Action Inventory of Strengths presented in Table 2 may thus be useful as it prompts people to rank the extent to which they see themselves as having different strengths. This, in turn, permits insight into how clients may see themselves and what strengths may be most relevant to them. Moreover, this not only exposes clients to an array of strength-based domains but helps to underscore that people vary across these areas and that no person needs to be “perfect” in all.

Table 2. Values in action – identifying strengths.

Core virtues	Character strengths
Wisdom and knowledge	1. Creativity 2. Curiosity 3.Judgement 4.Love of learning 5.Perspective
Courage	6.Bravery 7.Honesty 8. Perseverance 9.Zest
Humanity	10.Kindness 11.Love 12.Social intelligence
Justice	13.Fairness 14.Leadership 15.Teamwork
Temperance	16.Forgiveness 17.Humility 18.Prudence 19.Self-regulation
Transcendence	20.Appreciation of beauty 21.Gratitude 22.Hope 23.Humour 24.Spirituality

Of course, asking clients who self-injure to identify personal strengths is often easier said than done. Indeed, many individuals with lived experience of NSSI will be critical of themselves and experience emotions such as shame (Burke et al., 2021). Thus, acknowledging strengths in oneself may seem both difficult and foreign for many clients. Adding to this difficulty are the limitations of working memory that can occur in moments of acute, elevated distress, which often accompany NSSI (e.g. Klonsky & Glenn, 2009). As such, early on, an individual may have greater difficulty generating alternative solutions (e.g. not acting on an urge) when experiencing distress, let alone channelling, and attending to inner strengths.

To help, clinicians working with individuals who self-injure can proactively and collaboratively complete the VIA with the goal of developing a list clients can have on their person for use in the future (e.g. adding the list on a phone/tablet) as well as strategize how to recognize when the list may need to be accessed (e.g. identifying triggers, noticing when distress begins). Sometimes, and depending on the preferences and support network for a client, a strengths list can also be developed with a family member, romantic partner, or friend and then brought to sessions for discussion and reflection. In the end, keeping a list on-hand ensures that it is available during times of need and reduces the need to rely on recall/working memory during times of distress, which should increase the likelihood it will be used.

Another way to incorporate strengths into clinical work with people with a history of NSSI is to employ approaches grounded in gratitude and hope. Gratitude journals, for instance, have been linked to lower levels of distress, anxiety, and depression, which, as noted earlier, are commonly associated with NSSI (Jiang, Ren, Zhu, & You, 2022). Likewise, composing a letter expressing gratitude to someone or asking a client to develop a list of good things about life can work to reduce levels of depression, while increasing happiness (Southwell & Gould, 2017). As many people who self-injure experience depressive symptoms, this may help lessen the impact of such difficulties. Finally, in the context of NSSI, diary-focused interventions that aim to lessen self-criticism and enhance self-worth may also hold some utility in that they have been shown to – at least temporarily – yield reductions in NSSI engagement (Hooley & Franklin, 2018).

How do we find alternatives to self-injury?

Finding alternatives to self-injury that serve the same function is not an easy process. One of the reasons NSSI can be so hard to stop is that it is accessible, fast-acting, and effective at achieving aims like emotion regulation. Other coping strategies, such as distraction, relaxation techniques, or exercise require effort and practice to be effective. In our view there are three ways we can think about finding alternatives to self-injury: 1. Reducing the urge in the first place; 2. Addressing any urges that occur; 3. Finding alternatives to self-injury in the moment.

Reducing the urge in the first place

Work from ecological momentary assessment studies, in which people are asked about their mood and thoughts about self-injury at numerous points throughout the day, shows that an individual’s negative affect is noticeably higher up to eight hours before they engage in self-injury – yet participants reported thoughts of self-injury only one hour before injuring (Kranzler et al., 2018). This provides a critical seven-hour window where an individual may be experiencing negative thoughts or feelings, yet may not be consciously aware of them until they have an urge to self-injure. In this context teaching emotional awareness is key to identifying these elevations in negative mood so that strategies to down-regulate can be implemented before they cascade into a cycle that can only be interrupted with self-injury.

It might be helpful to work with clients to better identify what they are feeling at regular points throughout the day. Emotional literacy (i.e. understanding and recognising one’s own emotions) can be developed by encouraging clients to identify somatic symptoms that act as an indicator, such as butterflies in the stomach that signal anxiety or fatigue that signals depressed mood. Clients can ask themselves: What am I feeling? Why do I feel that way? What (if anything) do I need to do about this feeling? Clients might like to keep a journal or use a mood tracking app to reflect their emotions, and notes on their observations when they try to understand them. Clients can thus develop a wider range of psychological language, be able to identify emotions quicker using thoughts and sensations, and recognize when active emotion regulation is needed. Increasing emotional awareness provides an opportunity to change or regulate the emotion before it becomes too intense. The skills training at the core of dialectical behaviour therapy (Linehan, 1993) may have benefits here as it focuses on enhancing capability in mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. Development of these skills will provide individuals with more preventative strategies in their toolkit, allowing them to build resilience in responding to emotional experiences, and reducing urges to self-injure.

Addressing any urges that occur

There is also a role for counselling psychologists in helping clients navigate urges to self-injure as they occur. As noted previously, urges to self-injure are a normal and expected part of NSSI recovery. For this reason, clients should not feel like they have failed, or have had a setback, when they experience urges (Gray et al., in press). The important thing is how they view and respond to these urges in real time. One option is to be self-compassionate and recognise that urges are a normal part of the process. Reappraising the urges (I’ve had a tough day so it is not surprising I want to self-injure; it doesn’t mean I need to act on this urge. These urges happen because self-injury helped me when I felt this way in the past, but I can try other things this time) can help to normalise the experience of urges and reduce the sense of urgency. Giving oneself a period of time before acting on the urge may also help. An individual might postpone engaging in self-injury for 15 minutes – during which the urge may subside, they may become distracted, or they may consult their support plan for an alternative to self-injury. Finally, an individual may “urge surf” or “ride the wave of emotion” – recognising that urges come and go, like waves on the shore, and merely noting and accepting their presence (Linehan, 1993; Marlatt & Gordon, 1985l; Ostafin and Marlett, 2008). In this way the client is not fighting the urge or trying to suppress it.

New alternatives

Finding alternative strategies that meet the same function as NSSI can be difficult, especially if an individual is in a state of high arousal and alternative options do not come readily to mind (Andover, Schatten, Morris, Holman, & Miller, 2017). Conducting a functional analysis will help identify the purpose self-injury serves and assist in identifying alternative strategies that serve the same need. Many third-wave cognitive behavioural approaches adopt this approach (e.g. Acceptance and Commitment Therapy, Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Emotion Regulation Group Therapy; Gratz & Gunderson, 2006; DBT; Linehan, 1993) and emphasise understanding the underlying processes rather than focusing on the self-injury per se.

Some clinicians advocate use of harm minimisation strategies, designed to serve as proxies to self-injury that are less medically harmful (Lewis & Hasking, 2021b). These strategies are typically designed to either: mimic the physical sensation of NSSI (e.g. snapping elastic bands on the wrist); mimic the experience of NSSI (e.g. drawing red lines on the skin); ensure the method of self-injury results in less medically severe injuries (e.g. choose a location on the body where self-injury will cause minimum tissue damage); or limit the damage caused by self-injury (e.g. by providing advice on wound care to minimise infection).

Although recommended by the UK National Institute for Health and Clinical Excellence (National Institute for Health and Care Excellence, 2013), there is a great degree of confusion and uncertainty about both the ethics and the effectiveness of harm minimisation strategies. Some argue that efforts to prevent or stop an individual self-injuring fundamentally demonstrate a lack of understanding about self-injury and are largely ineffective – in fact they can actually exacerbate self-injury rather than reduce it (Sullivan, 2017). In this case, we could respect a client’s autonomy to decide to engage in self-injury and thus implement strategies to minimise the harm (Inckle, 2011). Sullivan (2017) suggests that healthcare professionals may be ethically bound to allow harm minimisation practices as a way to balance harm associated with self-injury and a client’s autonomy, and there have been recent calls to explore online communities as a space for provision of harm minimisation content (Preston & West, in press).

Yet individuals with lived experience of self-injury differ in their views on how effective harm minimisation techniques are. While some feel more empowered engaging in such strategies, others suggest that anatomical knowledge may be used to engage in more severe self-injury (Davies, Pitman, Bamber, Billings, & Rowe, 2020). A recent study of health records in the UK noted that only 3% of patients reporting self-harm (broadly defined) used harm minimisation strategies, but of these, most found them helpful (Cliffe et al., 2021). However, when strategies are viewed as helpful, the effect is short-lived (Wadman et al., 2020). Further, some individuals view replacement methods (e.g. rubber bands) as a form of self-injury, and report that attempting to suppress the urge to self-injure subsequently leads to more severe self-injury. For these reasons harm minimisation strategies are not recommended as a first line of defence as a replacement for self-injury (Washburn & Washburn, 2019

What may be more helpful is the development of support plans that an individual can refer to when they feel the urge to self-injure (Lewis & Hasking, 2021a, 2023). Similar to safety plans for suicide prevention, support plans can be used to help a client identify triggers for self-injury, note strategies that have helped them in the past, and list people they could call for support. Importantly, these support plans can be matched to the intensity of an urge, or the level of arousal an individual is feeling. The benefit of support plans is they can be developed while a client is calm, and able to think of effective strategies that meet their needs at different points in time. There are a number of Apps available to assist individuals in making a support plan, which can then be stored on a phone for easy access (see Table 3).

Table 3. Example of a support plan for individuals who self-injure.

My warning signs	How do I know I am heading into a time I might self-injure?	e.g., I feel hopeless; I’m stressed at work; I’m snapping at my friends
My reasons not to self-injure	It’s easy to forget reasons not to self-injure when the urge is intense	e.g., my friends will be upset; I don’t want any more scars; I don’t want self-injury taking control of my life
Alternatives to self-injury	What are some other coping strategies that have worked in the past?	e.g., go for a run; talk to a friend; listen to music
People I can turn to	Who can I turn to for support?	e.g., best fiend; parent; online support networks
Professional supports	If I need professional support where can I turn?	Write down the contact details of your GP, psychologist, emergency contacts

How do we address underlying adversities?

Self-injury does not occur in a vacuum. As a result, it very often co-exists with a range of mental health difficulties (e.g. anxiety, difficulty coping, self-criticism, negative body image) and, at times, mental illness (e.g. eating disorders, major depression, post-traumatic stress disorder, borderline personality disorder; Bentley, Cassiello-Robbins, Vittorio, Sauer-Zavala, & Barlow, 2015). As highlighted earlier, NSSI engagement can also heighten risk for suicide (Kiekens et al., 2018). Taking this together, a comprehensive assessment in the early stages of the therapeutic relationship to understand a person’s historical (e.g. trauma events) and ongoing adversities (e.g. depressive symptoms, unsupportive relationships) is recommended. Doing so permits a deeper understanding of the contexts and circumstances that may play a role in one’s experience of NSSI, thereby illuminating where more focused psychological support may be needed. It is not the aim of this paper to highlight the most appropriate treatments for any psychological comorbidity (e.g. anxiety disorders, depressive disorders, PTSD). Consideration should be given to evidence-based interventions that best serve the purpose and the context for that individual. As such, this might include family therapies, cognitive behavioral approaches, group therapies, or any other evidence-based approach the clinician and client are comfortable with.

Upon identifying the overall context in which NSSI occurs, clinicians will be better positioned to work toward addressing these adversities. This should involve a tailored approach that suits a client’s needs (e.g. addressing primary versus secondary concerns first) while also consulting with any corresponding empirical literature to ensure a research-informed approach (e.g. if a client has an anxiety disorder, using a therapeutic but evidence-supported intervention). Also critical, however, is accounting for historical, cultural, and systemic considerations (e.g. cultural understandings of mental illness that may accompany NSSI, recognition of systematic racism and oppression that may make it difficult for clients to trust or fully engage with a traditional, Western approach to therapy). As such, prior to embarking on a particular line of intervention (e.g. cognitive-behavioural therapy for anxiety), reflection, cultural humility, and professional consultation – or at times outside referral – may be needed to ensure a sensitive and appropriate approach is used, that suits a client’s context.

How do we foster acceptance of scarring?

Although not applicable to all individuals with lived experience of NSSI, scarring represents a salient concern for many individuals with lived experience. The psychosocial impact of NSSI scarring can be significant, with research indicating that the extent of one’s NSSI scarring and its concealment is associated with more negative scar cognitions as well as symptoms of anxiety and depression (Burke, Ammerman, Hamilton, Stange, & Piccirillo, 2020). Other research indicates that people report shame, embarrassment, and distress about having scars as they can conjure up painful memories, serve as a reminder of NSSI and emotional pain, and may hinder one’s view of their own recovery (Lewis & Mehrabkhani, 2016). Beyond the impact of scarring itself, people have also reported experiencing inappropriate and perhaps very hurtful reactions to their scars (e.g. people pointing, staring, or negatively commenting on one’s scars) which can exacerbate these feelings and contribute to stigmatisation. Although many people have reported these more difficult experiences when it comes to NSSI scarring, people with scarring from NSSI invariably hold diverse views of, and have different ways of relating to, their scars. In some cases, individuals have mixed views toward their scars (e.g. vacillating from acceptance to non-acceptance, seeing them differently across various contexts; Lewis, 2016). In others, people view scars positively and have more acceptance of their scars; for example, scars may be viewed as symbolic of inner fortitude and a sign that one has overcome adversity (e.g. Lewis, 2016). Taken together, scarring must be on the radar of counselling psychologists with their work with clients who engage in NSSI. And, given the diverse ways people may view their scars, it is essential that clinicians refrain from making assumptions about how a client may feel about their scars and instead respectfully explore this with a client.

Building from the above, several therapeutic modalities may be helpful in terms of bringing about a more accepting view toward NSSI scarring. One such approach is cognitive behavioral therapy (CBT; Beck & Weishaar, 1989) and its application to NSSI (e.g. Walsh, 2012), which offers collaborative means to a) identify what people’s thoughts about NSSI scars may be (e.g. I hate who I am for having scars, my scars mean I’m a weak person) and b) work to reframe these thoughts in a more accepting way (e.g. I have scars from NSSI but they do not define who I am; my self-injury scars symbolise my strength to overcome adversity). By reframing one’s scar-related thoughts that arise across different contexts, their negative impact should wane over time. As this occurs, people may also develop greater, scar acceptance. Another approach that may offer utility is acceptance and commitment therapy (ACT; Hayes, Luoma, Bond, Masuda, & Lillis, 2006), which has been flagged in prior work for its potential to help clients who experience shame and who otherwise may struggle accepting their scars from NSSI (Lewis, 2016). ACT places emphasis on diminishing shame while fostering acceptance of the self. It may be therefore be fruitful in addressing some of the very emotions that scarring foments. In a similar manner, compassion-focused therapy (CFT; Gilbert, 2009) may work to lessen shame and cultivate more kindness and compassion toward the self. Indeed, CFT has been implicated not only for NSSI but NSSI scarring specifically (Lewis, 2016; Lewis & Mehrabkhani, 2016). Finally, beyond working on scar acceptance, helping clients to manage distress that comes from scarring may be needed. Here, dialectical behaviour therapy (DBT) may help given its use for NSSI more generally and its utility in fostering distress tolerance and coping with emotional pain (Turner, Austin, & Chapman, 2014).

One final area warrants attention with regard to NSSI scarring, namely the decision to no longer conceal them. For many individuals this can be a significant decision in that it signals a shift in how they view not only their scars, but also themselves. In these instances, it can be helpful to foster open dialogue about this decision to understand what this might mean to a person. Part of the conversation should address the different positive (e.g. feeling resilient and empowered) and potentially negative consequences (e.g. negative reactions from others) associated with allowing one’s scars to be visible. Ultimately, this is a decision that only a person with lived experience of NSSI should make. However, by discussing the various outcomes that this may bring about, individuals will be better positioned to make an informed choice that suits them. Regardless of what that decision may be, ensuring that people with lived experience of NSSI have a coping plan in place to address any negative consequences would be essential; this can be accomplished by drawing on many of the coping strategies embedded in the approaches used to address NSSI urges, and underlying adversities discussed earlier. Further, there may be merit in incorporating DBT strategies centred on interpersonal effectiveness (e.g. assertiveness) as they may help individuals when responding in situations in which they are asked about their scars. As discussed next, the decision to no longer conceal one’s scars may also have relevance to the broader choice of sharing one’s NSSI experiences with others.

How do we help an individual navigate disclosures?

Many people who engage in NSSI are hesitant to share their experience with others. Although there are many reasons for this (e.g. not being ready to stop, feeling socially isolated), anticipated stigma represents a significant barrier to telling anyone else about their experience (Staniland, Hasking, Lewis, Boyes, & Mirichlis, 2022). Even when in treatment for an associated mental health concern, less than one third of clients will disclose NSSI to their therapist (Whitlock et al., 2011). Fears about disclosing NSSI are not unfounded. A recent review found that negative reactions to disclosure (e.g. judgement) were reported in all research studies in which individuals were asked about reactions to disclosure (Park & Ammerman, 2020), and in some cases were associated with further self-injury as well as suicidal thoughts and behaviours (Long, Manktelow, & Tracey, 2015). Conversely, recipients of disclosure were likely to report that they would be supportive, although this varied based on the characteristics and perceived motivation for self-injury (Park & Ammerman, 2020). Disclosing NSSI can be an important step in seeking support (Hasking, Rees, Martin, & Quigley, 2015). Disclosure in online contexts is associated with an increased sense of belonging and support (Lewis, 2016), while disclosure to family members is associated with increased prospective support-seeking and implementation of alternative coping strategies (Hasking, Rees, Martin, & Quigley, 2015). With that said, although it can be beneficial for youth to share their NSSI with caregivers, caution should be taken when working with youth whose caregivers are unsupportive or abusive (Hasking et al.). Clinicians should therefore bear this in mind when working with young clients.

We often think of disclosure of NSSI as a one-off instance – that one discloses their experience of self-injury to someone and then it is done, with no need for a follow-up discussion. But disclosure is a continuing and ongoing process. An individual may disclose different aspects of their experience at different times, to different people, in different ways, for different reasons. A clinician can work with a client to develop a plan for disclosing NSSI – if that is something the client wishes to do. There are many factors to consider in disclosing NSSI (see Table 4). These include: motivations for disclosure (what does the individual want to achieve?); characteristics of NSSI (does the individual have visible scars?); interpersonal factors (what is the nature of the relationship with the recipient of disclosure?); self-efficacy (does the individual have the capacity to explain their self-injury to someone else?); anticipated psychological outcomes (e.g. how will the individual feel after disclosing NSSI?); anticipated social outcomes (e.g. what impact will disclosure have on the relationship with the recipient?); and the setting for disclosure (e.g. is there a quiet space and time to disclose; Table 3). Of course, not all disclosure is voluntary. Others may learn of an individual’s history of self-injury by observing wounds or scars, or could hear about it from a third party. Counselling psychologists can work with individuals to anticipate these inadvertent disclosures and plan how the person may navigate them.

Table 4. Factors to consider in the decision to disclose NSSI.

Motivations	NSSI characteristics	Interpersonal factors	Self-efficacy	Psychological Outcomes	Social outcomes	Setting the scene
Why do I want to disclose NSSI? What do I hope will happen when I disclose? What do I actually want to communicate?	Do I have NSSI scars visible to others? Do I continue to self-injure? Would I consider myself “recovered”? Are there underlying concerns or thoughts of suicide that accompany my NSSI?	Is it relevant to the other person? Do they need to know? How well do I know this person? How close is the relationship? What do I expect the other person to do or say in response to disclosure?	Do I have the strength to disclose NSSI? What words will I use to tell the other person?	How do I expect to feel after I disclose my NSSI? What are the good outcomes that could occur? What are the less favourable outcomes that could occur? What will I do if there is a poor outcome?	How will disclosure impact this relationship? Will disclosure have any impact on other areas of my life (e.g. work)	Where and when will I disclose my NSSI? Choose a quiet & comfortable location where you will have plenty of time and not be interrupted

How do we generate self-acceptance?

A main aspect of our person-centred framework of NSSI recovery is the view that all individuals have capacity to develop self-acceptance over the course of their recovery experience (see Lewis & Hasking, 2021a, 2023). In some instances, this self-acceptance may emerge organically through the use of the many strategies discussed throughout this paper. For example, people may begin to feel more accepting toward themselves and thus develop a more positive outlook for the future as they cultivate efficacy to resist NSSI urges, as underlying adversities are addressed (e.g. depression, trauma) and begin to view their scars in a more resilient manner. Nevertheless, there are additional approaches germane to fostering acceptance of the self that can be harnessed in clinical work with people who self-injure.

Much like working on other components of our person-centred framework, becoming accepting of oneself does not occur immediately. Understandably, many people will find this hard and may have additional concerns about how others may view and accept them – especially once others know about their NSSI. For instance, some individuals in a client’s life may hold rigid and stigmatising beliefs about NSSI or may not be able to offer what a client needs (e.g. validation). Moreover, learning to accept oneself can permeate numerous domains of one’s life outside of recovery – both in the short- and long-term.. By becoming more self-accepting, it is important that this involves coming to see all aspects of oneself, including any perceived flaws or difficulties in a more compassionate light. Doing so may help minimise any tendency to apply value-laden concepts (e.g. being “good” or “bad” or “right” or “wrong”) to evaluate oneself. Fully accepting all aspects of the self is not something that is easy, or potentially even realistic, for anyone. People will judge themselves at different times – the importance is how the individual responds to this self-judgment. Encouraging the individual to be less self-critical, and respond to these thoughts with compassion, will help foster self-acceptance.

As discussed in the context of addressing NSSI scars, approaches rooted in developing self-compassion may also help to foster self-acceptance. In line with Neff’s (2003) model, self-compassion comprises three parts, namely: self-kindness (i.e. relating to oneself in a kind manner, versus one shrouded in self-directed criticism, harshness, and judgment), common humanity (i.e. seeing that psychological pain and suffering are part of the broader human experience, which also entails acceptance of the entirety of one’s imperfections as no single person is perfect), and mindfulness (i.e. intentionally adopting a balanced and non-judgemental approach to one’s feelings instead of emotional avoidance). With these elements in mind, practitioners can work with clients to build self-compassion by drawing on a range of exercises available online (see: www.self-compassion.org). For example, people can engage in perspective-taking exercises in which they take a moment to reflect on how they might respond to a close friend who is suffering and how they can, in turn, respond to themselves in a similar manner. Additionally, individuals might be encouraged to compose a letter to themselves in which they communicate compassion toward themselves from the vantage of a caring, loving friend. As a final example, clients might start a self-compassion journal or diary in which the focus of entries is on the three components of self-compassion.

What do we mean by building resilience and finding meaning?

In tackling these different aspects of NSSI recovery individuals can start to foster self-efficacy to resist urges to self-injure, implement alternate strategies, and value themselves for all the strengths they possess. Practicing new coping skills, practicing self-compassion when thoughts or urges arise, and considering the multifaceted nature of disclosing their experiences to others can help build resilience, and a sense of being able to cope with adversity. Indeed, clients will encounter adversity at different points in the future. But by practicing these new skills they will be better equipped to navigate these instances

Finding meaning and purpose in life can give individuals something positive to focus on and take away from a focus on self-injury. How this happens will vary person to person but finding meaning may arise from an examination of strengths, improved interpersonal skills and connection with others, or setting and meeting goals. Through self-acceptance and consideration of what their scars mean to them, individuals may also find meaning in their self-injury; seeing it as a sign of resilience, of strength, and courage, rather than a source of shame. Along these lines, recent research indicates that as people navigate their personal recovery journeys, they begin to develop more positive self-views (e.g. as being resilient, worthy) and a sense of hope which in turn, fuels a belief in their capacity to work toward a range of life goals (e.g. trying new activities, working toward a career goal) and tackle obstacles along the way (Farrell et al., 2023).

Conclusion

Central to our person-centred framework is the person; the individual sitting in the therapist’s office with their unique experiences, challenges, and goals. It is important to us that this framework resonates with individuals with lived experience and is seen as acceptable to them. Anecdotally we can report that we have received unanimously positive feedback both for the framework that underlies this paper, and for the practical strategies we recommend in this paper, in response to workshops we have presented, on social media, and through unsolicited emails. Naturally, future work empirically assessing the acceptability of the framework to people with lived experience is warranted. We are also mindful that the recommendations outlined here are primarily based on the experiences of individuals living in Western countries. Work with individuals with lived experience in non-Western countries (e.g. China, Pakistan, India) mirrors the themes from those in Western settings (Meheli & Lewis, 2022; Naz et al., 2021; Wong & Chung, 2022); hence we think our framework will have international utility. However, further work exploring how NSSI recovery is conceptualised in non-Western countries would guide refinement of the framework.

In conclusion, a respectful and non-judgemental approach to working with individuals who self-injure is critical, not only to establishing rapport, but to conveying that you seek to understand what self-injury means for them, and are not making assumptions about the causes, meanings, or outcomes of self-injury. Attending to aspects of the framework such as understanding NSSI recovery is not a linear process and setting realistic expectations avoids focusing solely on the self-injury – a topic a client may find difficult to discuss and may not be ready to change. As the process is non-linear it is important to continue to come back to the framework, to consider which aspects might be most relevant for the client in this particular moment – this will change over time which affords clinicians flexibility in how they work with clients to address self-injury. Ultimately, by adopting a person-centred approach, and valuing that the client is the expert in their own experience, a collaborative approach to NSSI recovery can be fostered, resulting in enhanced outcomes for both client and counselling psychologists.

Disclosure statement

No potential conflict of interest was reported by the authors.