Non-suicidal self-injury, youth, and the Internet: What mental health professionals need to know

Non-suicidal self-injury (NSSI) is the direct, deliberate destruction of one’s own body (e.g., cutting, hitting or burning of the skin) in the absence of suicidal intent [13]. NSSI represents a salient mental health issue in adolescents with consistent lifetime prevalence rates of 13.9 to 21.4% [13, 14] and an average of 13 incidents of NSSI occurring in the most recent 12-months among those who have self-injured [15]. NSSI may confer risk for suicide [16, 17] and has numerous concomitants and risks, including: repeated NSSI, physical injury/scarring, dysregulated emotion, and various psychiatric symptoms (e.g., anxiety, depression) [13].

Youth and young adults have daily Internet access and engage in more online social networking and video sharing than any other age group [1, 18, 19]. Since these age groups also have the highest NSSI rates [20], and adolescents who self-injure may engage in more online activity than those who do not self-injure [5, 21], it is perhaps not surprising that there has been an influx of NSSI content online in recent years. In 2010, the International Society for the Study of Self-injury (ISSS) recognized the emergence of NSSI activity on the Internet and the importance of research in this area. Online communication about the impact of NSSI e-material has also received media attention. In 2011 alone, there were over 400 news stories published globally, most of which focused on the impact this e-material may have on those who access it [22].

Research indicates that the Internet may represent a preferred medium for otherwise isolated youth and young adults to communicate with others—namely, others who self-injure [9]‐[12, 23, 24]. One part of the Internet’s appeal stems from the anonymous nature of interaction it provides; indeed, research indicates that anonymous e-communication may hold particular appeal for those who experience psychological distress and other emotional difficulties [9, 12, 25, 26] – many of the factors associated with NSSI risk [27].

The most commonly reported benefit associated with some online NSSI activity is that of social/peer support. Many youth and young adults who self-injure go online to share their NSSI experiences and connect with others who self-injure [10]‐[12, 28]; this may be particularly appealing to individuals who may not feel comfortable discussing their NSSI experiences offline [9, 10, 12]. Furthermore, some research suggests that individuals involved in NSSI e-communities report reductions in NSSI behaviour subsequent to joining these groups [28]. In sum, there seem to be some advantages associated with some forms of online NSSI communication. To this end, more research is needed to determine the extent to which online NSSI activity has benefits and for whom. It will also be important to ascertain what types of online activities have benefits as well as the nature of these benefits (e.g., the impact of social support on NSSI behaviour). Although there may be some benefits associated with online NSSI activity, as discussed next, online NSSI activity may pose several risks.

On many websites and e-forums, NSSI methods and tips about how to conceal the behavior are shared between users [9, 12]. First-aid tips are also shared, including ways to prepare oneself for NSSI (e.g., cleaning a razor) and how to tend to wounds after NSSI (e.g., how to clean a wound) [9]. Adolescents who self-injure and who access this material may therefore be exposed to learning new ways to self-injure, how to prepare for and carry out NSSI, and how to hide this from others (e.g., friends, family). This may thwart the likelihood of help seeking for some individuals. It may also engender the belief that help is not needed for NSSI. Thus, in addition to youth learning new NSSI-related strategies the nature of this content may reinforce NSSI. Similar to the above noted need to examine the phenomenon of NSSI reinforcement, the impact of sharing NSSI strategies should also be studied further. For example, it will be important to understand whether some youth are more influenced by these strategies and whether this associates with aspects of NSSI behaviour (e.g., using new methods to injure).

Many websites and e-communities post trigger-warnings [9, 10]. These warnings are intended to warn users that website content may trigger NSSI. That is, as a result of accessing NSSI content, individuals may experience emotional upset, and with that, an increased urge to injure; in turn, this may lead to NSSI engagement. Recent findings provide initial support for this. In a content analysis of personal NSSI websites, several individuals reported on their website that they experienced NSSI urges and even self-injured pursuant to seeing NSSI imagery or reading graphic NSSI descriptions [9]. In another study examining users’ responses to NSSI photographs shared within an e-forum, some individuals reported that seeing NSSI images triggered them and/or would trigger others to self-injure whereas others reported that the images were not triggering [32]. Thus, although online activities as a whole have not been proven to result in self-injury for all viewers, collectively, these findings provide preliminary support for the widespread clinical assumption that some people are triggered by graphic NSSI material. Moreover, these findings indicate the need to further explore how people may be differentially impacted by NSSI images (e.g., who is impacted, how people are impacted).

In summary, it is likely that many individuals who self-injure also engage in online activities related to NSSI. Despite the mentioned benefits associated with these online activities (e.g., support from others, reports of reduction of NSSI), there are also potential risks (e.g., maintenance of the behavior, triggering material). Therefore, it is important for clinicians who work with adolescents who self-injure to consider online activity in assessment and treatment contexts, at least to assess the possible benefit or harm for the particular client – a sentiment echoed in calls from researchers to assess Internet activities of youth who self-injure in clinical contexts [7]‐[9, 12, 29]. Although some general guidance strategies have been offered [8, 29], to date, there is a lack of detailed guidelines pertaining to how Internet activities could be assessed and monitored. An assessment rubric is provided below for professionals working with youth who engage in NSSI concerning their online activities. Of course, the focus on assessing, monitoring and intervening around online activities is done within the broader context of the overall functioning of the youth. It is important to acknowledge that due to the limited research in the area, these guidelines are tentative but empirically informed and derived from research examining approaches used to manage NSSI [27, 33] and problematic online behaviour among youth [34].

When working with youth who engage in NSSI, the scope and nature of the patient’s online activities must be addressed. However, the precise manner of how to comprehensively assess such online activities is rarely addressed within the literature. Below, the essentials of assessment, intervention, and monitoring are described.

A second consideration when working with youth around their online NSSI activities is the pervasiveness of online activities in their lives and the discrepancy in perspectives regarding online activities between adolescent culture and that of many mental health professionals. Online activities are an intrinsic part of adolescents’ lives and the use of e-communities and social networking sites for social support concerning any issue is commonplace, whereas for many mental health professionals the pervasiveness of online activities in the lives of their patients is not necessarily relevant, understandable, or recommended. Indeed, for a large number of youth, online interactions are (a) an inherent part of their culture, (b) highly accessible and available, and (c) often very enjoyable. Because online activities are so accepted, pervasive, and rewarding it may be very challenging to stop them - even when assessment suggests they may be harmful. Thus, the assessment, intervention, and monitoring of this behaviour is complex and cannot be avoided by simply asking the patient to stop all online activities.

Next, a brief assessment of the frequency, duration, and time of day of online activities (cumulatively, including all activities) fosters awareness of the extent of the exposure. If it becomes clear online behaviours are disrupting daily life activities (e.g., school, sleep, eating), this is an added concern. Finally, a review of the functional log is essential to understand the function of the online activities and to effectively evaluate the potential harm/benefits of the behaviour to the youth. Evaluating possible antecedents contributing to the youth seeking out unhealthy online activities is useful when reviewing the function log, however, a natural limitation of having a client use a functional assessment to record their online activities is the potential problems with self-report accuracy. While determination of potential harm is a central factor in the log analysis, it is important to recognize that, for some youth, online activities may provide much needed support. Clinicians need to be cautious in assuming that all online activities will pose harm. If the functional analysis reveals behaviours that are clearly impeding the youth from recovery then intervention to change the online activities is needed.

As indicated earlier, altering online activities in youth may be extremely challenging. Asking the youth to stop engaging in the online activities may result in the behavior becoming secretive, which compromises treatment. It is recommended that the first step in attempting to change the behavior is to assess the readiness for change using the stages of change model [35]. The stages of change approach has been used for the treatment of Internet addiction [e.g., [34, 36] and may be useful in approaching youth who are deeply invested in online NSSI activity. A particularly helpful aspect of this approach is motivational interviewing, which enhances the youth’s desire to change his/her online activities. Although motivational interviewing has not been used directly to alter online NSSI activities, Kress and Hoffman [33] have used it to increase motivation to change amongst individuals who self-injure; it has also been used to increase motivation to change among individuals with Internet addiction [34].

In seeking to effect change in online NSSI activities of youth it is suggested that beyond encouraging offline activities, substituting healthier online activities may be more effective than attempting to eliminate online activities altogether. Redirecting youth to healthier online activities with continued monitoring of the effects of these activities through the log review is recommended with the goal of establishing a pattern of online behaviours that is beneficial (and not harmful/triggering) to the youth. From here, each session should include a brief probe concerning online activities, which can be integrated as a part of the overall assessment of the youth’s functioning. Sudden changes in online activities may signal a change in the adolescent’s emotional wellbeing.

Research conducted over the past several years has helped to advance knowledge about the nature of NSSI content and communication on the Internet. Although there may be some benefits associated with some online NSSI activity, there are a number of risks meriting the attention of mental health professionals who work with adolescents who self-injure. When working with youth who engage in both NSSI and related online behaviour, it is important to conduct a comprehensive assessment to gain insight into the types and extent of activities and their corresponding antecedents and consequences. A Functional Assessment can help determine what may be reinforcing about the youths’ online activity and how this may impact NSSI. From here, approaches rooted in the stages of change model [35] and motivational interviewing [33, 35, 36] may be particularly useful when monitoring these activities, reducing the impact of more pernicious online material, and helping adolescents who self-injure develop healthier online behaviours.