How Are Self-Injury and Suicide Related?

This is an excerpt from Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones, by Janis Whitlock, PhD, and Elizabeth Lloyd-Richardson, PhD.

It’s not unusual for young people who are struggling with painful feelings to engage in self-injury — things such as cutting, burning or scratching themselves until they bleed. Knowing that a child is intent on harming themselves is very upsetting to parents, and many worry that self-injury is a sign that their child is suicidal.

Self-injury and suicidal behaviors — imagining, planning or attempting suicide — are related, but the relationship between the two is confusing. Because they can look similar, it can be very difficult to tell the difference between them. But there are important differences in the intention as well as the danger: Self-injury is virtually always used to feel better rather than to end one’s life. Indeed, some people who self-injure are clear that it helps them to avoid suicide. In fact, the technical term for self-injury is non-suicidal self-injury, or NSSI.

Self-injury and suicide differ in multiple ways, including:

The intent: The intent of self-injury is almost always to feel better, whereas for suicide it is to end feeling (and, hence, life) altogether.

The method used: Methods for self-injury typically cause damage to the surface of the body only. Suicide-related behaviors are much more lethal. Notably, it is very uncommon for individuals who practice self-injury and who are also suicidal to identify the same methods for each purpose.

Level of damage and lethality: Self-injury is often carried out using methods designed to damage the body but not to injure the body badly enough to require treatment or to end life. Suicide attempts are typically more lethal than standard NSSI methods.

Frequency: Self-injury is often used regularly or off-and-on to manage stress and other emotions. Suicide-related behaviors are much more rare.

Level of psychological pain: The level of psychological distress experienced in self-injury is often significantly lower than that which gives rise to suicidal thoughts and behaviors. Moreover, self-injury tends to reduce arousal for many of those who use it and, for many individuals who have considered suicide, is used as a way to avoid attempting suicide.

Presence of cognitive constriction: Cognitive constriction is black-and-white thinking — seeing things as all or nothing, good or bad, one way or the other. It allows for very little ambiguity. Individuals who are suicidal often experience high cognitive constriction. The intensity of cognitive constriction is less severe in individuals who use self-injury as a coping mechanism.

Aftermath: Although unintentional death does occur with self-injury, it is not common. The aftermath of a typical self-injury incident is short-term improvement in sense of well-being and functioning. The aftermath of a suicide-related gesture or attempt is precisely the opposite.

Despite differences and intention, suicidal thoughts and behaviors and self-injury do share common risk factors. Some of these include:

• High emotional sensitivity
• A history of trauma, abuse, or chronic stress
• Extreme emotion or lack of emotion
• A tendency to suppress emotions coupled with few effective mechanisms for dealing with emotional stress
• Feelings of isolation (this can be invisible in people who seem to have many friends/connections)
• A history of alcohol or substance abuse.

Because of these common risk factors, it is important for you to know that youth who self-injure are also at increased risk for suicidality. Our work shows that about 65 percent of youth who self-injure will also be suicidal at some point (though many will not go beyond having suicidal thoughts). For many, self-injury is used alone or in combination with other behaviors as a way to keep emotional distress or disconnectedness at a manageable level.

Although suicidal thoughts and behaviors can occur before self-injury is used, in most cases, suicidal thoughts and behaviors coincide with or come after self-injury starts. It is also important to note that only 36 percent of adults who self-injure in the United States reported having ever felt suicidal while engaging in self-injury, meaning that the majority of individuals who injure have never felt suicidal while engaging in self-injury.

Although self-injury does not cause suicide, the other important thing to know about the relationship between self-injury and suicide is that the very act of engaging in self-injury reduces inhibition to suicidal behavior if someone becomes suicidal. In other words, having “practiced” injuring the body repeatedly makes it easier to actually injure the body with suicidal intent.

Other factors that can place someone at greater risk of moving from self-injury to suicide include:

• Greater family conflict and poor relationship with parents
• More than 20 lifetime NSSI incidents
• Psychological distress in the past 30 days
• A history of emotional or sexual trauma
• Greater feelings of hopelessness
• Identifying self-hatred, wanting to feel something, practicing or avoiding suicide as reasons for self-injury
• High impulsivity and engagement in risky behaviors
• Substance use
• A diagnosis of major depressive disorder (MDD) or PTSD

These risk factors may be present individually or in clusters. The more of these your child has, the higher their risk is of at least having suicidal thoughts (this is called “suicidal ideation”).

What is especially important for you to know is that one of the most powerful protective factors against moving from self-injury to suicide is a feeling of connectedness to parents. Indeed, the consistency with which parents show up in our studies as important sources of support for their children is one of the reasons we wrote this book!

Janis Whitlock, PhD, is the founder and director of the Cornell Research Program on Self-Injury and Recovery. Elizabeth E. Lloyd-Richardson, PhD, is an associate professor of psychology at the University of Massachusetts, Dartmouth. This piece is an excerpt from Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones, from Oxford University Press.