By Janis Whitlock, Stephen P. Lewis, Imke Baetens, and Penelope Hasking
This post is the latest in a series on college student mental health and well-being.
Conversations about the mental health and well-being of college students often underestimate the prevalence and impact of non-suicidal self-injury (NSSI) in college settings. NSSI is defined as deliberate, direct damage to one’s body (e.g., cutting, burning, bruising) but without conscious suicidal intent and for reasons falling beyond the purview of socially or culturally accepted practices (International Society for the Study of Self-Injury 2018). NSSI is in most cases a way to regulate intense and unwanted emotions/thoughts. It is an understandably baffling behavior for many people. Why would people deliberately hurt themselves but also say that it helps them feel better? Are students who deliberately injure themselves suicidal? How should colleges respond?
The visceral association between self-injury and suicide and the challenges it poses to staff, faculty, and other students make it an important topic for consideration. But despite the unique challenges NSSI poses, relatively little coverage is devoted to understanding it in conversations of college mental health. This may be in part a result of a misunderstanding about the prevalence of NSSI on college campuses. Research shows that approximately one in five college students have engaged in self-injury, although rates can vary substantially, ranging from 7 percent to 44 percent. These variations in statistics exist, in part, due to the difficulty in detecting and identifying students who self-injure.
What is non-suicidal self-injury?
Non-suicidal self-injury can include a wide variety of behaviors, but common forms include cutting, self-scratching, burning, and punching objects. The risk of NSSI is particularly high in adolescence: the mean age at onset peaks around the age of 14–15. A second peak is common around the age of 20 in college samples. Self-injury is often episodic, which means people will use it for a while but may go days, months, or even years without self-injury episodes or urges before self-injuring again.
There are few clear demographic variables associated with NSSI. While some studies find a modest difference in self-injury prevalence by sex in favor of females, many studies find no sex difference at all. Most studies find no significant differences by socioeconomic status or ethnicity. Finally, a consistent finding across many studies is that bisexual women may report especially high rates of NSSI.
There is no single clear set of risk factors for NSSI. It has been associated with a wide variety of other mental health conditions (e.g., depression and anxiety disorders, disordered eating, PTSD, and borderline personality disorder) as well as abuse or trauma, emotion-regulation difficulties, poor interpersonal relationships, substance abuse, disordered eating behaviors, and/or negative perceptions of the body. However, many individuals who self-injure do not meet criteria for a mental illness. So it is important not to assume that because students self-injure, they have a mental illness.
That said, NSSI is associated with increased odds of suicide ideation, plans, and attempts. While NSSI does not appear to lead to suicide, it can reduce inhibition to suicidal behavior, and it is not uncommon for suicidal thoughts and/or behaviors to co-occur with NSSI. This means it is important to conduct periodic suicide assessments with students who self-injure, even if the NSSI has not recently occurred.
Why do students self-injure?
NSSI is best understood as a self-soothing technique that assists those who use it to calm down when experiencing negative emotions, feel the need to self-punish, or seek a sense of reintegration when dissociated. Self-injury works for a number of physiological and neurological reasons, and because it provides immediate relief—or dissociation—from emotional discomfort, it can become a quick and easy go-to for some students.
Nevertheless, while NSSI can feel like an effective way to manage emotions, it can also be highly disruptive and disturbing to individuals who may be aware of it (often friends and family, but can include roommates, RAs, or others who encounter wounds, blood, or scars as well). Coming into contact with NSSI, even if not directly, can lead to secondary feelings of trauma or increased feelings of stigma on behalf of individuals who injure, particularly when they see others respond with disgust, anger, or pity.
What is the impact of self-injury on campus?
While knowing a student who self-injures can be upsetting, of course the dominant impact is on the student who self-injures. In addition to potentially signaling the presence of other mental health conditions, NSSI can compromise academic life. For example, in a recent study of the relationship between NSSI and academic performance, freshmen with a history of NSSI had significantly lower grade point averages after a year than students who did not self-injure. This was largely attributable to the associated stress, anxiety, and emotion regulation challenges.
Having students who self-injure on campus can also pose challenges for experienced administration and counseling and psychological services providers (CAPS), who have to make critical decisions about when, where, and how to intervene. Protocols for managing student NSSI vary from campus to campus, but the core challenges remain the same. When a student is receiving support, does not present an elevated risk for other more acute mental health concerns (e.g., suicidal thoughts and behaviors), and does not cause disruption to others on campus, there is likely to be little need for administrative intervention. However, when any of the above conditions are not met, university administration, most often in conjunction with CAPS, will typically have to discuss more serious options for supporting the student while simultaneously balancing the needs of other affected individuals and systems. Yet, because NSSI can be a harbinger of suicidal thoughts and feelings and because it can be so jarring for others, there inevitably will be cases in which interventions beyond regular therapy are needed, such as requiring the student to take a leave of absence.
This is where having a clear approach to NSSI is both useful and important. Not only does having a set of general guidelines help protect universities from liability in cases where NSSI results in unintended severe injury or where it is accompanied by suicidal behaviors, but it also benefits the student who self-injures. Colleges are well-positioned to assist students who self-injure by assessing student needs and resources, such as therapy and other support services. They also can be instrumental in decreasing stigma in the staff, faculty, and student body, and helping individuals and key units respond effectively. Ultimately, these steps increase the likelihood of early detection, effective response, and increased access to information about alternative supports for those who do not seek mental health services.
Tips for responding to NSSI on campus
NSSI can pose challenges to administrators that elude easy remedy, even when clear protocols are in place. Because college campuses are larger and more administratively diffuse than secondary school settings, it can be challenging to monitor student status. In light of the increasing mental health burdens campuses face, demands for mental health services often exceed available resources (Lewis et. al., in press.) For campuses to effectively address complex self-injury cases, students require multiple conversations with mental health staff and, when deemed appropriate by campus mental health professionals, these conversations include parents. Beyond this approach, colleges need a comprehensive plan to improve mental health literacy across campus, which might include:
Helping key responders understand why
One of the most common questions that individuals unfamiliar with NSSI will have is “why?” In light of its prevalence, many students will have encountered it in their peer group, but there are a significant number of adults who have not encountered self-injury in any meaningful way. Because it can be so confusing, it is helpful for staff and peers to understand that for a variety of psychological and physiological reasons, self-injury can help those who use it feel a sense of relief. They especially need to know that despite what it looks like, students use it in an attempt to feel better and not to end their lives.
Both institutions and individuals need to know how to respond effectively. At the institutional level, this means communicating a clear protocol for triaging NSSI behavior. Both the CAPs-linked response teams and the larger community of faculty and staff need to know how to recognize it and how to respond, ideally in ways that encourage students to use campus support services. To do this, they need to react with compassion.
Identifying referral pathways and resources
Lastly, stopping self-injury behavior and dealing with the underlying psychological processes that engender it nearly always requires some degree of therapeutic support, especially if self-injury is the preferred method of coping. Ensuring that at least some of the CAPS providers are well-trained in NSSI and identifying community-based providers with NSSI expertise are critical parts of the referral pathway.