Received 06/03/11

Revised 01/20/12
Accepted 01/31/12
DOI: 10.1002/j.2161-1874.2013.00011.x

Conceptualizing Nonsuicidal Self-Injury

as a Process Addiction: Review of
Research and Implications for Counselor
Training and Practice
Trevor J. Buser and Juleen K. Buser
Nonsuicidal self-injury (NSSI) may be characterized as a process addiction for
some individuals who self-injure. The authors review findings on the addictive
features of NSSI, including compulsivity, loss of control, continued use despite
negative consequences, and tolerance.
Keywords: nonsuicidal self-injury, process addiction, behavioral addiction

Nonsuicidal self-injury (NSSI) refers to the damaging of bodily tissue without

suicidal intention and without social sanction (Favazza, 1998). Cutting, burning, hitting, biting, and severe scratching are among the common methods of
NSSI documented in the literature (Claes, Houben, Vandereycken, Bijttebier,
& Muehlenkamp, 2010; Gratz & Chapman, 2007; Lloyd-Richardson, Perrine,
Dierker, & Kelley, 2007). Authors have argued that engagement in NSSI involves
addictive components (Briere & Gil, 1998; Faye, 1995) similar to those of other
behavioral or process addictions (e.g., eating disorders, Internet addiction, and
compulsive gambling). Discussions of NSSI as a process addiction, however,
are rather brief in nature and outdated (Briere & Gil, 1998; Faye, 1995). There
exists a clear need for a comprehensive review of recent evidence and theory
that support the classification of NSSI as a process addiction. Moreover, authors
of proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000)
have defined a new diagnostic category for NSSI, which features addictive
characteristics (APA, 2010b). In view of this important development, a review
of this topic is timely. In this article, we provide an overview of NSSI, including the prevalence rates of this behavior and its definition. Subsequently, a
rationale is presented for classifying NSSI as a process addiction. Implications
for counselor training, clinical practice, and future research are discussed.

Overview of NSSI
For the purposes of this article, NSSI is defined specifically as the direct,
deliberate, self-inflicted damaging of a superficial/moderate amount of
Trevor J. Buser and Juleen K. Buser, Department of Graduate Education, Leadership, and Counseling, Rider University. Correspondence concerning this article should be addressed to Trevor J. Buser,
Department of Graduate Education, Leadership, and Counseling, Rider University, Memorial Hall
202-M, 2083 Lawrenceville Road, Lawrenceville, NJ 08648 (e-mail: tbuser@rider.edu).
2013 by the American Counseling Association. All rights reserved.
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bodily tissue, which is performed without the intent to die and without social
sanction (Favazza, 1998). Favazza (1998) developed a classification system
that identified three main types of NSSI: (a) major NSSI, (b) stereotypic
NSSI, and (c) superficial/moderate NSSI. The category of major NSSI refers
to extreme, severe forms of self-injury (e.g., auto-castration), which are less
frequent in occurrence than other types of NSSI, involve a large amount of
tissue damage, and are typically associated with psychosis or intoxication
(Favazza, 1998; Klonsky, 2007). The category of stereotypic NSSI pertains to
self-injurious behaviors that occur as a clinical feature of neurological illness or developmental disability (e.g., autism and LeschNyhan syndrome;
Favazza, 1998). As Favazza (1998) and Yates (2004) further explained, stereotypic NSSI is distinguished by its apparent lack of emotional expression
or social meaning (given its performance with or without others in view).
Superficial/moderate NSSI refers to self-injurious behaviors that damage
tissue only to a superficial or moderate level and are not associated with
neurological illness or developmental disability (Favazza, 1998). Superficial/
moderate NSSI often involves an emotional response (e.g., tension relief)
and/or social meaning, unlike stereotypic NSSI (Favazza, 1998; Yates, 2004).
Moreover, superficial/moderate NSSI may be episodic or repetitive in its
pattern of performance (Favazza, 1998; Yates, 2004). The focus of this article
is on superficial/moderate NSSI, which is the most common type of NSSI
(Favazza, 1998), as well as the type featured in the proposed DSM-5 (scheduled for publication in 2013) diagnostic category for NSSI (APA, 2010b).
Studies on the prevalence of NSSI tend to examine either the frequency of
NSSI over a discrete period of time (e.g., 6 months) or the frequency of NSSI
during an individuals lifetime (i.e., lifetime NSSI). Briere and Gil (1998)
inquired into the frequency of NSSI over the past 6 months. Their results
showed that NSSI was performed by 4% of an adult nonclinical sample (N
= 927; mean age = 46 years; 50% male; 75% White, 11% Black, 7% Hispanic,
3% Asian, 2% Native American, and 2% other). Among younger populations, rates of NSSI are substantially higher. For example, Lloyd-Richardson
et al. (2007) reported that nearly half (46%) of adolescents (N = 633; mean age
= 15.5 years; 54% female; 51% African American, 44% Caucasian, 2% Asian
American, 1% Latino, and 2% other) in a nonclinical setting had engaged in
NSSI within the past year. In a psychiatric inpatient setting, Nock and Prinstein (2004) found that as many as 82% of adolescents (N = 108; mean age =
14.8 years; 70.4% female; 72% European American, 11% Latin American, 5%
African American, and 12% mixed ethnicityother) performed NSSI during
the past year.

NSSI as an Addiction
The following elements of addiction have been widely accepted: (a) compulsivity, (b) loss of control, and (c) continued use of the substance or behavior
despite negative consequences (APA, 2000; Coombs, 1997; Smith & Seymour,
2001). Authors have also discussed the role of tolerance in addictive behaviors
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and its connection to specific neurochemical processes, such as the endogenous

opioid system (EOS; Gianoulakis, 2001; Sandman & Hetrick, 1995; Sandman
& Touchette, 2001). In the following sections, we define these components
of addiction and review research indicating that engagement in NSSI may
involve each one. Attention is given first, however, to descriptions of this
behavior by self-injuring individuals who accentuate the addictive aspects
of NSSI. Taken together, these points of evidence suggest that engagement
in NSSI may function as a process addiction. The term process addiction refers to a class of addictive behaviors that does not involve the ingestion of
a substance (Hagedorn, 2009; Smith & Seymour, 2004).

Research on Self-Injuring Individuals

Characterization of NSSI
Both qualitative and quantitative researchers have found that individuals who self-injure perceive NSSI as an addictive behavior. Harris (2000)
analyzed written descriptions of NSSI from six self-injuring women (age
range = 2045 years; no other demographic data reported). The participants
were recruited from a national organization for people who self-injure
in the United Kingdom. One participant, in describing her engagement
in NSSI, stated, I really would like to stop self-harming but feel I cant
because I am addicted [emphasis added] to it. I couldnt live without the
release it gives me. The buzz [emphasis added] you get from it (p. 169).
Such explicit references to the buzz of NSSI liken this behavior to familiar
forms of addiction.
In a quantitative study on this topic, Nixon, Cloutier, and Aggarwal (2002)
surveyed 42 self-injuring adolescents (mean age = 15.7 years; 86% female;
97.6% White) from a clinical setting. In developing their survey questions,
the researchers used language from diagnostic criteria for substance dependence but made slight alterations so that these criteria referred to the
behavior of NSSI. The findings showed that, in describing their engagement
in NSSI, 97.6% of participants endorsed at least three of the seven criteria
for dependence and 81% endorsed at least five of the criteria.
Whitlock, Muehlenkamp, and Eckenrode (2008) reached similar conclusions
in their research with a nonclinical population. Their sample included 2,101
college students (age range = 1824 years, with 51% younger than 20 years
old; 56.3% male; 67% Caucasian, 17% Asian/Asian American, 4% Hispanic,
4% non-Hispanic Black, and 8% other). Two-hundred eighty-two participants
(13.4%) had engaged in two or more episodes of NSSI over the course of their
lifetimes. Within this group of participants who self-injured, three subtypes,
or classes, of self-injuring individuals were differentiated by the degree of
severity of engagement in NSSI. The findings showed that the most severe
group of individuals who self-injuredthose who used multiple methods
of NSSI, experienced higher levels of tissue damage, and had engaged in
NSSI within the past yearwas significantly more likely to view NSSI as
addictive in nature compared with other classes of self-injuring individuals,
whose severity of NSSI was only superficial or moderate. These findings
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suggest that some people who self-injure spontaneously characterize NSSI

as addictive (Harris, 2000) and, when asked directly about this issue, affirm
that there are addictive components to the performance of NSSI (Nixon et
al., 2002; Whitlock et al., 2008). The characterization of NSSI as addictive,
therefore, matches the experience of some individuals who self-injure and
is grounded in their own descriptions of this behavior.

Compulsivity
As noted earlier, authors have observed that a primary feature of addiction
is the compulsive use of a substance or behavior (Coombs, 1997; Sellman,
2009; Smith & Seymour, 2001). Indeed, Sellman (2009) asserted that addiction is fundamentally about compulsive behavior (p. 6). According to
the DSM-IV-TR (APA, 2000), compulsions refer to habitual behaviors that
are precipitated by a desire to avert or alleviate negative emotions. The
criteria for the proposed DSM-5 diagnosis of NSSI (APA, 2010b) include
reference to these aspects of compulsivity. Specifically, the criteria state that
engagement in this behavior may be (a) preceded immediately by negative emotions and (b) performed to serve the purpose of alleviating negative emotions. These two symptoms are not necessary conditions for the
ascription of a diagnosis for NSSI; however, they are sufficient conditions
for fulfilling one domain (Criterion B) of the proposed diagnostic criteria
(APA, 2010b). Additionally, to be diagnosed with the disorder of NSSI,
self-injuring individuals must engage repeatedly in the behavior, with it
occurring on 5 or more days in the past year (APA, 2010b). It is important
to note, therefore, that the proposed DSM-5 diagnosis for NSSI is consistent
with the view that people who self-injure perform NSSI compulsively, that
is, as a habitual means for averting or alleviating a negative emotional state.
A considerable amount of research adds further support to the notion
that individuals who self-injure engage in NSSI as a way to avert or alleviate unpleasant emotions. Klonsky (2007) recently reviewed the extant
research on functions of NSSI. His findings indicated that the majority of
people who self-injure identified affect regulation as a function of NSSI.
NSSI functioned as a means of altering the persons emotional state. An
example of this function was documented by Briere and Gil (1998), who
surveyed self-injuring individuals from clinical and nonclinical settings (N
= 93; mean age = 35 years; 89% female; 91% White) in one of their studies.
Eighty percent of this sample reported using NSSI as a means of distraction from negative emotions, and 75% of the sample described NSSI as a
means of tension reduction.
Several researchers, therefore, have found support for the view that persons
who self-injure use NSSI as a means for reducing negative emotion. Brain,
Haines, and Williams (2002) further noted that this affect regulation function
likely leads many self-injuring people to engage habitually in NSSI. To the
extent that engagement in NSSI becomes patterned over time and is targeted
at the reduction of painful emotions, it may be argued that many individuals who self-injure exhibit the hallmarks of compulsivity in this behavior.
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Loss of Control
A second primary component of addiction is the perception of losing
control over a behavior or the use of a substance. Individuals may desire
to reduce engagement in the addictive behavior but are unable to carry
out these intentions with consistency (Goodman, 2001; Smith & Seymour,
2001). This clinical feature of losing control is articulated in the DSM-IV-TR
(APA, 2000) diagnostic criteria for substance dependence as the persistent
desire or unsuccessful efforts to cut down or control (p. 197) the use of a
substance. Similarly, in conceptualizing process addictions, authors have
observed that the inability to curtail or cease engagement in a behavior,
such as gambling or sex, is a key aspect of this form of addiction (Goodman, 2001; Hagedorn, 2009).
Related to issues of control is the influence of ones cravings, or urges, to
engage in an addictive behavior. Cravings are involved in a variety of addictions (Preston et al., 2009; Tavares, Zilberman, Hodgins, & el-Guebaly,
2005). They have been characterized as the desire to engage in a behavior
(e.g., ingesting a substance) as well as the experience of tension or anxiety
in the absence of the behavior, which may be accompanied by physiological
reactions (e.g., elevated heart rate) and obsessive thoughts about performing the behavior (Skinner & Aubin, 2010). Blume (2004) argued that cravings play an important role in an individuals inability to stop a behavior,
given that cravings provide forceful motivation to return to the addiction.
Researchers have found that many individuals who self-injure experience
urges to perform NSSI and a loss of control over their engagement in this
behavior. Whitlock, Powers, and Eckenrode (2006) analyzed 3,219 posts,
or written statements, from 10 online NSSI message boards and classified
the posts with various content codes. One of these codes was addictive
elements (p. 412), which the researchers assigned to 288 posts (9%). In
approximately 10% of postings on the addictive elements of NSSI, posters
described multiple attempts to quit (p. 412) their performance of NSSI.
This theme described self-injuring individuals inability to stop engagement in NSSI despite a desire to do so. Additionally, 18% of postings on the
addictive elements of NSSI described self-injuring individuals inability to
control the urge to perform NSSI. As one poster described the behavior of
NSSI, It just haunts me and I dont think Ill ever get away from it (p. 412).
Briere and Gil (1998) also identified loss of control as a feature of individuals
performance of NSSI. In their mixed sample of clinical and nonclinical individuals who self-injured (N = 93), 34% of participants perceived themselves
as frequently losing control over their engagement in NSSI. Whitlock, Eckenrode, and Silverman (2006) reported that 21% of self-injuring individuals
from a sample of college students (N = 2,875; 73% between the ages of 18
and 24 years; 56.3% female; 64.7% non-Hispanic White, 17.1% Asian/Asian
American, 4.3% Hispanic, 3.7% non-Hispanic Black, and 10.2% other) had
the experience of injuring themselves more severely than expected. Lack
of control seems evident in such situations because acts of NSSI exceed the
individuals intentions or expectations.
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In accordance with such findings, authors of the proposed DSM-5 diagnosis for NSSI (APA, 2010b) have included reference to the urge to perform
NSSI and the experience of losing control. Specifically, the criteria for this
diagnosis state that, prior to performing NSSI, individuals may experience
an urge and period of preoccupation with the intended behavior that is
difficult to resist [emphasis added] (APA, 2010b, Criterion B). In these ways,
fundamental characteristics of addictionspecifically, loss of control and
the experience of urgeshave been embedded within the diagnostic criteria for NSSI. Although these criteria are not necessary conditions for the
diagnosis of NSSI, they are sufficient conditions for meeting one domain
of this new diagnosis.

Continued Use Despite Negative Consequences

An addiction is characterized, in part, by an individuals persistence in the
addictive behavior despite damaging effects of the behavior (Goodman, 2001;
Smith & Seymour, 2001). The DSM-IV-TR (APA, 2000) diagnostic criteria for
both substance abuse and substance dependence include mention of the recurrent use of a substance despite negative consequences. Process addictions, as
well, are typified by the continued use of a problematic behavior (Goodman,
2001; Hagedorn, 2009; Smith & Seymour, 2004). Researchers have also supported the relevance of this addictive feature to NSSI. For example, Nixon
et al. (2002) sampled a clinical population of 42 self-injuring adolescents. The
results showed that 73.8% of participants identified social problems emanating
from their engagement in NSSI. Furthermore, 95.2% of participants reported
that they continued to perform NSSI despite its damaging effects.
In a qualitative study, Mangnall and Yurkovich (2010) interviewed eight
female prison inmates (median age = 30 years; 29% Native American; no
other demographic data provided) who performed NSSI. The researchers
identified a pattern of engagement in NSSI, which emerged from participants descriptions. Participants reported that, typically, they felt negative
emotions, engaged in NSSI, experienced relief from their negative emotions,
and then received disciplinary action from prison officials for engaging in
NSSI. This negative consequence of disciplinary action would then give
rise to additional negative emotions, and the participants would resume
the cycle of performing NSSI. In this example, the participants continued
use of NSSI despite negative consequences is evident. In fact, as with other
forms of addiction, the negative consequences led these participants back
to the familiar coping mechanism of NSSI.
The proposed criteria for the DSM-5 diagnosis of NSSI (APA, 2010b)
are in alignment with the view that individuals who self-injure continue
to engage in NSSI despite negative effects. The proposed criteria include
reference to impairment caused by NSSI in important areas of functioning,
such as social relationships and academic performance. Additionally, as
stated previously, the proposed criteria define NSSI as a recurrent behavior, which takes place on 5 or more days in the past year (APA, 2010b).
Missing in the diagnostic criteria, however, are explicit phrases such as
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recurrent use despite consequences, which would mirror the substance abuse
and dependence criteria of the DSM-IV-TR (APA, 2000).

Tolerance
Tolerance has been defined in the DSM-IV-TR (APA, 2000) as the reduced
impact of a substance over time, when the amount of substance ingested
is held constant, or an individuals need to ingest larger amounts of a
substance to experience the intended result (e.g., tension reduction or
euphoria). Tolerance is a criterion of substance dependence (APA, 2000)
and has also been implicated in the development of process addictions.
For example, the DSM-IV-TR (APA, 2000) diagnosis for pathological gambling
includes the following criterion, which is retained in the DSM-5 proposal for
the gambling disorder (APA, 2010a) and highlights issues of tolerance: needs
to gamble with increasing amounts of money in order to achieve the desired
excitement (p. 674). Given that tolerance is characteristic of many addictions, its presence in self-injuring individuals experience of NSSI would
provide additional reason to classify NSSI as a process addiction.
Although research in this area is preliminary, there is empirical support
for the view that some self-injuring individuals develop tolerance to the
behavior of NSSI. Researchers have found that engagement in NSSI becomes
progressively intense and frequent for some people who self-injure (e.g.,
Favazza & Conterio, 1988; Nixon et al., 2002). Along this line, Nixon et al.
(2002) reported that 97.6% of self-injuring adolescents (N = 42) from a clinical setting experienced their engagement in NSSI becoming more frequent
and severe over time. Additionally, 73.8% of participants reported that they
engaged in more severe or frequent NSSI to experience the same outcome.
In a mixed methods investigation of individuals who self-injured (N =
250) by Favazza and Conterio (1988), the experience of tolerance was voiced
by some participants. One participant offered the following description of
her history of NSSI, which was classified by the researchers as representative of the sample: At first a bruise or a scratch was effective, but later
it took more blood to ease the explosive tension. Now I cut my veins to
get results (p. 26). Similarly, in research with a sample of self-injuring
individuals from clinical and nonclinical settings (N = 43; mean age = 23.5
years; 58% female), Brain et al. (2002) found that the positive effect of NSSI
(specifically, reduction of arousal) was similar for individuals who engaged
in NSSI infrequently and those who engaged in NSSI habitually. Thus, it
may be that individuals who engage habitually in NSSI need increased
frequency of the behavior to obtain the same positive impact as individuals
who engage in lower levels of NSSI.
Toward explaining the development of tolerance among individuals who
self-injure, researchers have found that neurotransmitter systems, such as
the EOS, may be involved in the performance of NSSI. The EOS contains
the group of endogenous opioid peptides known as endorphins (Koneru,
Satyanarayana, & Rizwan, 2009). Endorphins contribute to the experience of analgesia (absence of pain) and increase an individuals sense of
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comfort and control or power (Koneru et al., 2009). The role of the EOS
has been widely discussed in connection with familiar forms of addiction,
such as alcoholism. Gianoulakis (2001) reviewed research on the role of
endogenous opioids in alcoholism and concluded that the ingestion of an
alcoholic substance initially increases levels of endorphins, which provide
sensations of comfort and contentment (Koneru et al., 2009).
Similarly, authors have suggested that engagement in NSSI may activate
the EOS as a result of the experience of pain accompanying NSSI (Sandman & Hetrick, 1995; Sandman & Touchette, 2001). The consequent release
of endorphins may then serve to improve the self-injuring persons mood
(Koneru et al., 2009; Sandman & Touchette, 2001; Yates, 2004). Authors have
further asserted that, as individuals who self-injure continue to activate the
EOS for the attainment of an intended result (e.g., improved mood), they
may develop tolerance to the endorphins triggered by NSSI (Sandman &
Hetrick, 1995; Yates, 2004). Consequently, more severe or more frequent
levels of engagement in NSSI would be required for the self-injuring individual to reach the same mood state (Yates, 2004). This theory is partially
supported by studies showing that the use of naltrexone, which is an opiate
antagonist that obstructs the pain-relieving effects of the EOS, has been successful in reducing a range of self-injurious behaviors (Griengl, Sendera, &
Dantendorfer, 2001; Roth, Ostroff, & Hoffman, 1996; Sonne, Rubey, Brady,
Malcolm, & Morris, 1996).

Alternative Presentations of NSSI

In this article, we have argued that engagement in NSSI may function as
a process addiction for some individuals who self-injure. It is unlikely,
however, that addictive features of NSSI are present for all people who
self-injure. Performance of NSSI may result from a wide variety of causes
and motivations by self-injuring individuals (Klonsky, 2007; Yates, 2004).
For example, in contrast to the affect regulation function of NSSI highlighted earlier, social functions of NSSI have been documented by Nock
and Prinstein (2004). In such cases, individuals use NSSI for facilitating
particular types of interactions with others (e.g., avoiding negative interactions or promoting positive interactions). It is unclear, however, whether
the addictive properties outlined previously, such as compulsivity, would
be applicable to those who self-injure primarily as a means of influencing
social exchanges. Further complicating the issue are findings that most
individuals who self-injure identify more than one function served by this
behavior (Lloyd-Richardson et al., 2007).
In light of these findings, we conclude that engagement in NSSI has addictive features for some people who self-injure. More research is needed to
understand whether particular types of self-injuring individuals (e.g., those
who perform NSSI primarily for tension reduction) are more likely to experience NSSI as a process addiction. In this sense, NSSI may be conceptualized
in a manner similar to eating disorders, which have diagnoses separate
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from substance dependence in the DSM-IV-TR (APA, 2000) or separate from

substance use and addictive disorders, to use the language of proposals for
the DSM-5 (APA, 2010c), but are recognized as addictive behaviors for some
individuals (Cassin & von Ranson, 2007; Garner & Gerborg, 2004).

Discussion
As discussed earlier, there are numerous reasons for classifying NSSI as a
process addiction. Several behavioral indicators of addiction seem relevant
to the performance of NSSI, including compulsivity, loss of control, and
continued use despite consequences. Furthermore, there is evidence that
some individuals who self-injure experience the phenomenon of tolerance
in relation to their engagement in NSSI. The characterization of NSSI as a
process addiction has important implications for both counselor training
and clinical practice.

Counselor Training
If behaviors are classified as process addictions, counseling students are
more likely to receive training in the area (Hagedorn, 2009). Several authors
have commented that students currently receive minimal training in the
assessment and treatment of NSSI (Allen, 1995; White, McCormick, & Kelly,
2003). In view of the proposal for a new DSM-5 diagnostic category for NSSI
(APA, 2010b), it is likely that training programs will turn more attention
to NSSI in course work on psychopathology and diagnosis. However, the
conceptualization of NSSI as a process addiction would likely increase its
inclusion in training programs furtherfor example, in course work specifically on the topic of addiction or in foundational courses in the curriculum.
The 2009 Council for Accreditation of Counseling and Related Educational
Programs (CACREP) Standards stipulate that addiction is covered in the
core curriculum for both school counseling and clinical mental health
counseling students (CACREP, 2009, Standard II.G.3.g.).
In addition, the classification of NSSI as a process addiction may yield
advancements to the way students are trained to assess and treat NSSI.
Exposure to specific assessment tools, which focus on the addictive elements of NSSI, could assist students in delivering a comprehensive assessment of NSSI. Nixon et al. (2002) created seven assessment items for NSSI,
which target addictive elements based on diagnostic criteria for substance
dependence. These items address the following symptoms: increasing
frequency and/or intensity of NSSI, continued used despite cognizance
of the damaging nature of the behavior, heightened anxiety when NSSI is
halted, distress around NSSI behavior, social concerns as a consequence of
NSSI, tolerance (i.e., increased severity and/or frequency of NSSI for the
same outcome), and lengthy amount of time demanded by NSSI. Alternatively, students could be trained to attend to three behavioral indicators of
addiction in their assessments of NSSI: compulsivity, loss of control, and
continued use despite consequences (Coombs, 1997; Smith & Seymour,
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2001, 2004). These behavioral components are often referred to as the three
Cs of addiction (Smith & Seymour, 2001, 2004) and provide a succinct means
for students in tracking addictive elements of NSSI.
Our conclusions also imply that students should be trained in counseling
interventions that protect the physical well-being of clients who self-injure. If,
for some self-injuring clients, greater levels of intensity or frequency of NSSI
are required to achieve the same intended effect (Nixon et al., 2002), then these
clients may be at increased risk for serious tissue damage over time. Progressive engagement in NSSI by some individuals who self-injure is particularly
alarming in view of findings that many of these individuals experience a loss
of control over this behavior (Briere & Gil, 1998; Whitlock, Eckenrode, & Silverman, 2006). Counseling students, therefore, need training in safety issues
relevant to NSSI and intervention strategies that protect clients from serious
and foreseeable harm (American Counseling Association, 2005, Standard B.2.a.).
Ideally, students would receive instruction in the indicators of escalating
engagement in NSSI (e.g., severity of tissue damage, recent engagement
in NSSI, utilization of multiple methods of NSSI) and intervention strategies that match the level of severity (e.g., training in additional coping
tools, involvement of a clients support system, or the development of
safety plans). Students may also benefit from the inclusion of case studies
in their course work, which portray clients who engage in progressively
severe forms of NSSI. One is reminded of the participant in the study by
Favazza and Conterio (1988) who began her performance of NSSI with
light scratches but progressed to cutting her veins to ease the explosive
tension (p. 26). By practicing the use of specific questions about issues of
tolerance (e.g., Have you found that you need to self-injure more often
or more intensely to feel the relief you described?) and discussing levels
of intervention, students may be better positioned to assist such clients.

Clinical Practice
Cognitive behavior strategies have often been recommended in the treatment
of individuals who self-injure (Klonsky & Muehlenkamp, 2007). The classification of NSSI as an addiction, however, suggests the use of counseling
models that have been applied to substance addictions and other process
addictions. One such approach is motivational interviewing (MI), which
originated in the treatment of addiction (Miller & Rollnick, 2002; Rollnick
& Miller, 1995). In working from an MI framework, a counselor accepts the
clients subjective worldview and avoids a confrontational stance (Rollnick
& Miller, 1995). These principles coincide with findings from research on
the treatment of NSSI. In a qualitative study of women (N = 10; age range
= 1823 years; 80% White European/American, 10% African American, and
10% Latina) who sought counseling for NSSI, Craigen and Foster (2009)
reported that many participants noted the importance of a counselors
nonjudgmental, understanding posture toward their disclosures about NSSI.
Another important feature of MI is its emphasis on recognizing and working
within the clients current degree of motivation to change. In drawing upon
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the Stages of Change model (Prochaska, DiClemente, & Norcross, 1992),

proponents of MI assume that clients transition through several stages of
motivation on their way toward changing addictive behaviors (Rollnick
& Miller, 1995). These stages of motivation (specifically, precontemplation,
contemplation, preparation, action, and maintenance) range from a state
of minimal cognizance that any problem exists to, at the other end of the
spectrum, committed efforts to change addictive behaviors and to maintain
steps of progress in change.
One common strategy of MI, which often facilitates a shift in the stage of
change, is to highlight the clients own ambivalence about change (Miller
& Rollnick, 2002; Rollnick & Miller, 1995). Clients typically hold wishes
to continue an addictive behavior alongside concerns that the behavior is
ultimately destructive or unhealthy. Even clients at the precontemplation
stage, who have much uncertainty that a problem exists, may eventually
hint at frustrations with the addictive behavior. Applied to the presenting
issue of NSSI, the principles of MI imply that counselors can help clients
by empathizing with both sides of their ambivalence, including the recognition of positive, meaningful functions served by NSSI (e.g., social
communication or affect regulation) and the apparent downsides, such as
the scarring of the body, distance from friends and family members, or the
experience of shame.
Toward this end, Miller and Rollnick (2002) also proposed the use of a
decisional balance sheet (p. 16). In this exercise, clients record the costs
and benefits of continuing their current behavior, as well as the costs and
benefits of stopping their current behavior. As the balance sheet often illustrates, clients possess very complicated views about addictive behaviors
and a great deal of ambivalence, which are often left unacknowledged
by clients (Rollnick & Miller, 1995). According to Miller and Rollnick, the
heightened recognition of ambivalence, in turn, prompts the client to take
some action to reconcile the perceived conflict.
Group interventions based on MI are also available and may be applicable to
the treatment of individuals who self-injure. For example, Ingersoll, Wagner,
and Gharib (2002) created a 10-week (90-minute sessions) group counseling model for individuals with substance abuse. This group intervention
was informed by the nonconfrontational underpinnings of MI and teaches
clients the Stages of Change model (Prochaska et al., 1992). Furthermore,
clients engage in creative exercises, such as arts-based activities, which
apply principles of the Stages of Change model to their personal lives and
highlight clients own goals and values. Such exercises may be relevant
for self-injuring individuals, who also likely face a complicated blend of
allure and aversion to their performance of NSSI (Miller & Rollnick, 2002).

Future Research
Although a few investigations have specifically examined the addictive nature
of NSSI (Nixon et al., 2002; Whitlock et al., 2008), more research in this area is
warranted. Specifically, researchers should explore which functions of NSSI
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(e.g., affect regulation) are most closely related to self-injuring individuals

experiences of compulsivity, loss of control, continued use despite negative
consequences, and tolerance. As noted previously, it may be that the addictive
components of NSSI are exclusive to particular classes of individuals who
self-injure (e.g., those who engage in NSSI for affect regulation). Additionally,
the research surrounding the phenomenon of tolerance among people who
self-injure and the role of endogenous opioids is still in its nascent stages.
Future studies may include the implementation of longitudinal designs, which
track self-injuring individuals severity of engagement in NSSI and perceived
effects over time. Finally, the field could benefit from controlled studies that
apply MI interventions in the treatment of people who self-injure. This type
of research would make an important contribution to the knowledge of the
treatment options for self-injuring clients.

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