Non-suicidal self-injury (NSSI) is intentional damage to one’s body tissue without suicidal intent. It can include cutting, burning, hitting and severe scratching. About one in five adolescents reports a lifetime history of NSSI, yet many providers receive little training in how to identify or address it.
NSSI is distinct from a suicide attempt, but it’s also an important risk factor for future suicidal behavior. Nicholas Westers, PsyD, ABPP, Clinical Psychologist at Children’s HealthSM and Associate Professor at UT Southwestern, is helping providers navigate that tension through research that brings greater clarity and consistency to NSSI care. These four evidence-based practices can help providers identify and respond to NSSI while preserving patient trust.
1. Screening directly for NSSI alongside suicide risk
Suicide screening may not identify young people who use NSSI to manage distress. Asking about NSSI during a psychosocial assessment can help providers recognize the behavior earlier and determine what follow-up is needed.
A neutral introduction can make the question easier to answer: “Some young people hurt themselves on purpose, without intending suicide. Have you ever done that?” Giving examples may help patients recognize behaviors that they might not consider self-injury.
After a patient discloses NSSI, providers can assess suicidal thoughts, onset, frequency, methods and whether an injury has required medical attention. These dimensions are captured in Dr. Westers' SOARS model, a five-minute screening tool. “A positive screen always means follow-up, but it doesn’t always mean the emergency department,” says Dr. Westers.
2. Using respectful curiosity to reduce stigma
The way a provider responds can shape whether a young person feels safe continuing the conversation. “We aim for a low-key, dispassionate demeanor and respectful curiosity, a matter-of-fact approach,” says Dr. Westers. That stance matters, because patients are often closely attuned to a provider’s language, facial expressions and emotional reactions.
This approach also helps providers set aside assumptions that NSSI is attention-seeking or manipulative. In fact, attention is among the least common reasons young people give for self-injuring. Instead, providers can explore what the young person may be trying to express and what support may be missing. Neutral, person-centered language can reduce shame, preserve trust and encourage patients to keep talking.
3. Understanding the function before suggesting alternatives
Because NSSI often provides immediate emotional relief, a patient may not want to stop or may doubt that stopping is possible. Advising them to simply stop may have little effect.
Providers can instead explore how NSSI serves the patient. Dr. Westers contributed a chapter to The Oxford Handbook of Nonsuicidal Self-Injury, published in 2023. In it, he highlights key questions to integrate into patient interviews. Dr. Westers suggests beginning with validation: “It sounds like this has been helpful at times. What does it do for you?” NSSI may help regulate overwhelming emotions, counter numbness, communicate distress or meet another need. Understanding that function helps guide the choice of alternatives that serve a similar purpose.
Readiness for change also matters: Asking whether the patient has considered stopping can guide treatment planning and referral. Referral to a mental health professional experienced with adolescent NSSI is especially warranted when the behavior is frequent, escalating or paired with suicidal thoughts. Sharing the behavior's function, onset and frequency, any co-occurring suicidal thoughts and the patient's readiness to change supports continuity of care when referring.
4. Matching wound assessment to the provider’s clinical role
Providers may also face uncertainty about whether and how to assess NSSI wounds. For medically trained clinicians, examining and treating an injury may be appropriate when clinically indicated. For most mental health professionals, however, routine visual inspection falls outside their training and scope of practice.
In a 2024 paper, Dr. Westers recommends beginning with a verbal assessment. “We’re trained to ask, not inspect,” he says. “We can learn what we need by asking the patient how they care for injuries and whether they’ve ever needed medical attention.” If the responses suggest a need for evaluation or treatment, they can refer the patient to a medical professional. This approach respects privacy while maintaining the therapeutic relationship.
Providers may intend to reassure patients by describing an injury using words such as “superficial” or “not that bad,” but these responses may invalidate the patient’s distress and could contribute to further self-injury. Factual, neutral responses can preserve trust and support appropriate care.
Leading the next phase of NSSI research
These four evidence-based practices are propelling the field toward more precise, patient-centered NSSI care. Future research will also refine the SOARS model to better identify characteristics associated with suicide risk and examine how patients experience visual wound assessments. By pairing research with training for pediatric residents, Children’s Health is translating emerging evidence into clearer clinical guidance while keeping patient trust at the center of care.
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