Self-Harm: Understanding Non-Suicidal Self-Injury and How to Help

Self-harm — particularly non-suicidal self-injury (NSSI) — is one of the most misunderstood behaviours in mental health. Public discourse tends to frame it in one of two unhelpful ways: as dramatic attention-seeking, or as a clear sign of suicidal intent. Neither framing is accurate for most people who self-harm, and both misunderstandings have real consequences: they prevent people from seeking or receiving the help they need, and they prevent those around them from responding in ways that actually help.

This article aims to offer a different perspective — grounded in research, destigmatising in tone, and practically useful for anyone who self-harms, knows someone who does, or wants to understand this behaviour more deeply. No graphic descriptions of methods are included.

What NSSI Is — and What It Is Not

The DSM-5 introduced Non-Suicidal Self-Injury as a separate condition requiring further study, distinguishing it clearly from suicidal behaviour. The defining characteristic of NSSI is that it is injury to oneself undertaken without suicidal intent — that is, the person is not attempting to end their life. This distinction is clinically and practically important, even though NSSI is associated with elevated risk of suicidal ideation over time.

NSSI is not attention-seeking in the manipulative sense the term implies. Research consistently shows that the majority of people who self-harm do so in secret and go to significant lengths to hide it. The shame associated with self-harm is pervasive, and the idea that it is performed for public attention does not match the reality experienced by most people who engage in it.

NSSI is also not a permanent state or an inevitable progression to more severe behaviour. Many people who self-harm during adolescence or early adulthood stop without any formal treatment. Understanding the functions it serves is the key to understanding why some people need professional support to stop, and what kind of support actually helps.

The Functions NSSI Serves

Asking "why do people self-harm?" is the right question — and the research has produced a nuanced answer. NSSI serves identifiable psychological functions, and understanding these is essential to responding compassionately rather than reactively.

• Emotion regulation: This is the most commonly reported function. When emotional pain becomes overwhelming — when feelings feel too big, too intense, too confusing to contain — physical pain can paradoxically provide relief. It shifts the focus from unbearable emotional experience to manageable physical sensation, and the physiological response (endorphin release, nervous system activation) can produce a sense of calm after the acute emotional storm. For people who have never developed alternative ways to manage emotional intensity, this mechanism can feel like the only available one.
• Interrupting dissociation: Some people self-harm not because emotions are overwhelming but because they feel nothing at all — a frightening numbness or disconnection from reality. The physical sensation of self-harm can break through this dissociative state and restore a sense of being present and real. "I needed to feel something" is a phrase clinicians hear frequently.
• Self-punishment: When shame, self-blame, or self-hatred are intense — particularly in people with histories of trauma, abuse, or profound self-criticism — self-harm can express and enact that self-condemnation. "I deserve this" is the internal logic. This function is particularly associated with trauma histories and complex presentations.
• Communication of pain: Some people who have no other language for their internal experience, or who have not been believed when they tried to express their pain verbally, use self-harm as a way of externalising what cannot otherwise be shown. This is closer to the "communication" interpretation that gets misread as "attention-seeking" — but the important point is that it is not manipulation; it is an attempt to make internal experience visible when words and direct expression have failed or been dismissed.

These functions explain why simply telling someone to stop — without offering or developing alternative ways to meet these psychological needs — is rarely effective, and can feel dismissive and shaming.

Who Is At Risk

Prevalence studies suggest that approximately 17–25% of adolescents engage in NSSI at some point, with rates lower but still significant in adults (around 6% in community samples). This makes NSSI considerably more common than many people realise.

Certain groups show elevated rates: young people (particularly adolescents and young adults), women (though male NSSI is underreported and understudied), people with histories of trauma or abuse, those with borderline personality disorder (where emotion dysregulation is a core feature), those with depression or anxiety disorders, and LGBTQ+ individuals (who face elevated rates of minority stress, social rejection, and discrimination).

NSSI frequently co-occurs with other mental health difficulties, particularly depression, anxiety, eating disorders, PTSD, and substance use. It is associated with elevated risk of suicidal ideation — not because NSSI "leads to" suicide, but because both are related to underlying psychological pain and difficulty regulating it. Any co-occurring suicidal thinking should be assessed and taken seriously by a professional.

How to Respond If You Discover Someone Self-Harms

The way you respond in the first moments after discovering that someone you care about self-harms can significantly influence whether they feel safe enough to seek help — or whether they retreat further into shame and silence.

Don't panic. A calm, steady response is more helpful than shock or visible distress, even if you feel frightened inside. The person is likely already carrying a great deal of shame, and an escalating or distressed response from you reinforces that what they are doing is terrible and shameful.

Don't shame or demand explanations. "How could you do this to yourself / to us?" "Why would anyone do this?" These responses, however understandable, centre your reaction rather than their experience and make it less likely they will open up further.

Don't make promises you can't keep. "Promise me you'll never do this again" puts the person in an impossible position — they may genuinely not be able to make that promise, and breaking it will compound their shame. Instead, focus on being a safe person they can come to.

Do lead with care: "I care about you and I'm concerned. Can you tell me what's going on for you?" The goal of the first conversation is to keep the channel of communication open, not to solve the problem in one conversation.

Do encourage professional help — gently, without ultimatums. "I think talking to someone who knows about this could really help you — would you be open to that?" Support them in making that contact rather than demanding it.

Safer Conversations About Self-Harm

If the person is willing to talk, several conversational principles help create a genuinely safe space:

• Listen without trying to fix: In the first instance, the most helpful thing is simply to hear what the person is going through. Resist the impulse to jump to solutions.
• Avoid catastrophising or minimising: Both extremes are unhelpful. "This is so serious, I'm scared you're going to kill yourself" (catastrophising) shuts down honest conversation. "It's not that bad, you'll be fine" (minimising) is dismissive and invalidating.
• Separate the behaviour from the person: The person is not their self-harm. The self-harm is a response to pain, not a defining characteristic.
• Follow safe messaging guidelines: Do not ask for specific details about methods, and do not discuss methods in any specificity. This is important for the same reasons as in suicide prevention — detailed method information can be harmful.
• Stay curious rather than judgmental: "What does it feel like before you do it?" or "What does it give you?" approach the behaviour with genuine curiosity about the person's experience rather than condemnation.

Evidence-Based Treatments

The most strongly evidenced treatment for NSSI is Dialectical Behaviour Therapy (DBT), developed by Marsha Linehan specifically to address emotion dysregulation and self-destructive behaviour. DBT combines individual therapy, skills group training, phone coaching, and therapist consultation. The four skill modules — mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness — directly address the functions that NSSI serves, teaching alternative ways to manage emotional intensity, tolerate distress, and communicate needs.

Evidence for DBT in reducing NSSI is robust across multiple randomised controlled trials. It is currently recommended as first-line treatment in most clinical guidelines for adolescents and adults who self-harm.

Cognitive Behavioural Therapy (CBT) adapted for NSSI addresses the thoughts, beliefs, and patterns of avoidance that maintain self-harm. CBT helps identify the triggers and thoughts that precede NSSI episodes and develop alternative cognitive and behavioural responses.

EMDR (Eye Movement Desensitisation and Reprocessing) is particularly useful when NSSI is connected to traumatic experiences, processing the underlying trauma that drives the self-punishing or pain-relief function.

Medication is not a primary treatment for NSSI itself, but may be important for treating co-occurring conditions (depression, anxiety, PTSD) that contribute to the emotional pain driving the behaviour.

Alternatives to Self-Harm When Urges Arise

Alternative strategies are not a substitute for therapy, but they can be genuinely useful in the moment as a bridge to more comprehensive treatment, or as part of a therapist-developed safety plan. The key is finding strategies that meet the same psychological function as the self-harm.

• For emotional overwhelm (the regulation function): The DBT TIPP skills — Temperature (holding ice cubes, splashing cold water on the face), Intense exercise (running, jumping jacks), Paced breathing (slow, diaphragmatic breath), and Paired muscle relaxation — are specifically designed to bring physiological arousal down rapidly. The ice cube technique is widely used: holding ice tightly in the hand creates intense physical sensation without causing tissue damage.
• For dissociation (the grounding function): Grounding techniques — the 5-4-3-2-1 sensory exercise, strong taste (lemon, chilli), physical movement — can bring attention back to the present moment. Strong smells, cold water on the face, or vigorous physical activity can all interrupt dissociative states.
• For self-punishment (the shame function): This function requires deeper therapeutic work, but in the moment, practices of self-compassion (such as Kristin Neff's self-compassion break) or writing the thoughts driving the shame can begin to create some distance from the self-punishing impulse.
• For communication (the expression function): Expressive writing, drawing, or physically externalising internal experience in another form can serve as an alternative channel. Sending a message to a safe person — "I'm struggling right now" — directly meets the communication need without self-injury.

A personalised safety plan, developed collaboratively with a therapist, is far more effective than generic alternative strategies. If you or someone you care about is self-harming, professional support is the most important step.

Practical Takeaways

• NSSI is not attention-seeking or suicidal behaviour — it serves real psychological functions that are worth understanding.
• Most people who self-harm do so in secret and carry significant shame; a non-judgmental, compassionate response is essential.
• Don't panic, don't shame, don't demand explanations — lead with genuine care and keep the door open.
• DBT is the most evidenced treatment; CBT and EMDR are also effective, particularly for trauma-related NSSI.
• Alternative strategies (ice, intense exercise, grounding) can help in the moment but are not a substitute for therapy.
• If you are the person who self-harms: you are not broken, you are not hopeless, and help exists that actually works.

Recovery is possible, and many people who have self-harmed for years find their way to a life in which they no longer need to. Take the next step: find a therapist experienced with NSSI and DBT, explore our posts on emotional regulation skills and DBT therapy, and take the PHQ-9 test to understand the full scope of what you may be experiencing.