2.5 Working with Suicidal and Non-suicidal Self-Injury Behaviors

Suicide has far-reaching impact.  Suicide and suicide attempts cause serious emotional, physical, and economic impacts. People who attempt suicide and survive may experience serious injuries that can have long-term effects on their health. They may also experience depression and other mental health concerns. Suicide and suicide attempts affect the health and well-being of friends, loved ones, co-workers, and the community. When people die by suicide, their surviving family and friends may experience prolonged grief, shock, anger, guilt, symptoms of depression or anxiety, and even thoughts of suicide themselves^[7].

The financial toll of suicide on society is also costly. In 2020, suicide and nonfatal self-harm cost the nation over $500 billion in medical costs, work loss costs, value of statistical life, and quality of life costs^[8].

There were 46,412 suicides among adults in 2021. But suicides are just the tip of the iceberg. For every suicide death, there were about^[9]:

• 3 hospitalizations for self-harm
• 8 emergency department visits related to suicide
• 38 self-reported suicide attempts in the past year
• 265 people who seriously considered suicide in the past year

Non-Suicidal Self-Injury

Self-injury is more common than most people realize, although the incidence has begun to stabilize over the last five years^[10].  The condition — clinically known as non-suicidal self-injury or NSSI — is characterized by deliberate self-inflicted harm that isn’t intended to be suicidal. People who self-harm may carve or cut their skin, burn themselves, bang or punch objects or themselves, embed objects under their skin, or engage in myriad other behaviors that are intended to cause themselves pain but not end their lives. (For the most part, tattooing and piercing are not considered NSSI because they are culturally sanctioned forms of expression.)

The most frequent sites of self-injury are the hands, wrists, stomach and thighs, though self-injurers may hurt themselves anywhere on the body. Results can be serious: About a third of students reporting NSSI in two college studies said they had hurt themselves so badly that they should have been seen by a medical professional, but only 5 percent sought treatment^[11]. As for adolescents, about 17 percent had engaged in NSSI at least once, according to an international meta-analysis of 52 studies^[12].

Reported self-injury is much less common in adults — about a 5 percent lifetime rate — and in most children. Overall, about 1.3 percent of children ages 5 to 10 self-injure, though rates climb significantly if the child has a diagnosed anxiety disorder or chronic mental distress, studies show.

Young white females tend to represent the public’s perception of NSSI, but at least 35 percent and as many as half of self-injurers may be male, studies also show. The number is uncertain in part because males present differently from females and may, therefore, be underreported. Females are more likely to engage in self-cutting, while males are more prone to deliberately bruising themselves, hurting themselves while taking a substance, or having others hurt them.

Demographic research shows that people self-injure regardless of race or socioeconomic status, but that sexual minority status may put young people more at risk. More gay or bisexual males report self-injury than heterosexual males, and bisexual females are especially vulnerable: About 47 percent of bisexual females (as measured by their ratings on the Kinsey scale on sexual orientation) self-injure. In a related vein, young people who are bullied or otherwise rejected by peers are more likely to self-injure than others. One study found that among 78 teens, those who were bullied or reported feeling victimized by bullying were more likely to injure themselves, and that depression intensified this association^[13].

Those who self-injure also are more prone to depression, hopelessness and dissociation, research also finds. Thus, researchers are studying the role of emotion dysregulation — difficulty discriminating between emotional states or knowing how to cope with or extricate oneself from negative emotional states — and finding a strong link with self-injury. Research also finds that NSSI is a strong predictor of later suicide attempts.  Students at five American colleges were followed over three years and those who self-injured at the beginning and did not report suicidal thoughts, plans or actions at the time, but who went on to engage in 20 or more self-injuring behaviors, were 3.4 times more likely to have attempted suicide by the study’s end^[14].

Symptoms of self-injury may include:

• Scars, often in patterns.
• Fresh cuts, scratches, bruises, bite marks or other wounds.
• Excessive rubbing of an area to create a burn.
• Keeping sharp objects or other items used for self-injury on hand.
• Wearing long sleeves or long pants to hide self-injury, even in hot weather.
• Frequent reports of accidental injury.
• Difficulties in relationships with others.
• Behaviors and emotions that change quickly and are impulsive, intense and unexpected.
• Talk of helplessness, hopelessness or worthlessness^[15].

Treatment and nursing care of individuals who self-injure overlaps with that of patients who have suicidal ideation. A safe environment free of items that can be used to self-harm is of utmost importance.

Prevention: Warning Signs of Suicide

Everyone can help prevent suicide by recognizing warning signs of suicide and intervening appropriately. Warning signs of suicide include client statements or nurse observations of the following^[17]:

• Feeling like a burden
• Being isolated
• Increasing levels of anxiety
• Feeling trapped
• Being in unbearable pain
• Increasing substance use
• Looking for a way to access lethal means
• Increasing anger or rage
• Exhibiting extreme mood swings
• Expressing hopelessness
• Sleeping too little or too much
• Talking or posting about wanting to die
• Making plans for suicide

See Figure 2.5b^[18] for five action steps for anyone to take to prevent suicide in someone experiencing suicidal thoughts or ideations. Nurses can educate others to take the following steps if they believe someone may be in danger of suicide^[19]:

• Call 911 if danger for self-harm seems imminent.
• Ask the person if they are thinking about killing themselves. Although asking this question can feel invasive, it is common for individuals with mental health problems to share their thoughts and plans regarding suicide. Asking them about suicide will not “put the idea into their head” or make it more likely that they will attempt suicide. In fact, by responding appropriately, you can help save their life by asking this question.
• Listen without judging and show you care.
• Stay with the person or make sure the person is in a private, secure place with another caring person until you can get further help.
• Remove any objects that could be used in a suicide attempt.
• Call or text 988 to reach the new nationwide Suicide and Crisis Line for a direct connection with compassionate, accessible care and support for anyone experiencing mental health-related distress.

Establishing a Safe Care Environment for Patients

Establishing a safe care environment is a priority nursing intervention for patients with suicidal thoughts or self-injury tendencies. Patients who have attempted suicide or are having suicidal thoughts are at continued risk for self-injury. Whether in a behavioral health facility, a general hospital unit, or in the emergency department, nursing care includes safety measures. These requirements include performing an environmental risk assessment, screening for suicidal ideation and thoughts of self-harm, assessing risk, documenting risk , following evidence-based written policies and procedures, providing information on follow-up care on discharge, and monitoring effectiveness of these actions in preventing suicides. These requirements are discussed in further detail in the following subsections.^[20]

Perform Environmental Risk Assessment

An environmental risk assessment identifies physical environment features that could be used by patients to attempt suicide. Nurses implement actions to safeguard individuals identified at a high risk of suicide and self-injury from environmental risks, such as continuous monitoring, routinely removing objects from rooms that could be used for self-harm, assessing objects brought into a facility by clients and visitors, and using safe transportation procedures when moving patients to other parts of the hospital.

In psychiatric hospitals and on psychiatric units within general hospitals, additional measures are taken to prevent suicide by hanging by removing anchor points, door hinges, and hooks. Patients may be asked to remove belts and shoelaces and turn in cigarette lighters, pens, and other belongings that may be used for cutting or strangling. Special bed linens may be provided that tear easily so an individual cannot suspend his or her body weight. Use of necessary medical equipment, such as orthopedic boots and splints or CPAP equipment must be carefully supervised. If patients have access to outdoor activities, they may need to have their clothing checked for rocks or sticks upon re-entering the unit.

Screen for Suicidal Ideation and Self-Injury

Patients being evaluated or treated for mental health conditions are routinely screened on admission to clinics, emergency departments, and inpatient care for suicidal ideation and self-harm. However, patients being treated for medical conditions often have coexisting mental health disorders or psychosocial issues that can cause suicidal ideation. These thoughts are not usually expressed by patients unless they are asked openly due to guilt, shame, and emotional distress. It is up to the healthcare team to ask. All patients aged 12 and older admitted for acute health care should be screened for suicidal ideation.

Assess Risk for Suicide and Self-Injury

An evidence-based suicide risk assessment should be completed on patients who have screened positive for suicidal ideation. Patients with suicidal ideation vary widely in their risk for a suicide attempt depending upon whether they have a plan, intent, or past history of attempts. Assessment for suicide risk includes asking about their suicidal ideation (i.e., thoughts of suicide), if they have a plan for dying by suicide, their intent on completing the plan, previous suicidal or self-harm behaviors, risk factors, and protective factors.^[21] When assessing for a suicide plan, notice if the plan is specific and the method they plan to use. The risk of acting on suicide thoughts increases with a specific plan. The risk also increases if the plan includes use of a lethal method that is accessible to the client. Knowledge of the extent of suicidal intent helps nurses plan for appropriate safety measures and interventions. For example, patients with strong ideation may need more frequent monitoring, or may not be allowed off the nursing unit for activities.

Assessing suicide risk is done at least once per shift and may be completed more often for higher risk patients. Many facilities use risk assessment tools for documentation. An example of an evidence-based suicide risk assessment tool that anyone can use with anyone, anywhere is the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS). The C-SSRS uses a series of simple, plain-language questions that anyone can ask. The answers help identify if a person is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs. Examples of questions include the following^[22]:

• Have you had thoughts of killing yourself?
• Have you thought about how you might do this?
• Have you done anything, started to do anything, or prepared to do anything to end your life?

For patients who self-harm, assessment for suicidal ideation should also be performed. In addition, patients should be asked about their history of self-injury, methods, and triggers for the behaviors.

Develop a Safety Plan

If a patient is assessed as a risk for suicide, a safety plan should be created in collaboration with the patient. A safety plan is a prioritized written list of coping strategies and sources of support that patients can use. The plan should be brief, in the patient’s own words, and easy to read. After the plan is developed, the nurse should problem solve with the patient to identify barriers or obstacles to using the plan. If the patient will be discharged soon, discussion should include where the patient will keep the safety plan and how it will be located during a crisis.^[23],[24]

For patients with self-injurious behaviors, the nurse engages in an open discussion of triggers, helping the patient to become aware of early emotional distress. The nurse and patient then formulate a plan to alert healthcare team members and use anxiety-reduction skills and coping behaviors.

Document Level of Risk for Suicide

After risk is assessed, it should be documented and communicated with the treatment team, along with the plan to keep the patient safe. It is vital for all health care team members caring for the client to be aware of their level of risk and plans to reduce that risk as they provide care.^[26] Nurses complete documentation regarding the level of a patient’s suicide and self-injury risk and associated interventions every shift or more frequently as needed, depending upon the patient status.

Follow Written Policies and Procedures

Nurses must follow agency policies and procedures addressing the care of individuals who are identified at risk for suicide to keep them safe. Patients may need one-to-one monitoring by a staff member when suicidal urges are severe. A room check may be required if staff suspects that the patient may have dangerous items in their possession. The nurse should ensure that staff members are informed and knowledgeable about the acuity levels of their patients and appropriate safety measures.^[27] The effectiveness of policies and protocols regarding suicide prevention should be evaluated on a periodic basis as part of overall quality improvement initiatives of the agency.^[28]

Caring for Injuries

Patients who have attempted suicide or have self-injured may need appropriate care for wounds. While nurses may be emotionally affected by seeing these types of injuries as well as past scars, it is important to take a caring but neutral approach when providing wound care. Open discussion of healing and prevention of future occurrences builds the therapeutic alliance and level of trust. Patients are more likely to be open to informing the nurse of self-injurious thoughts should they occur.