Non-suicidal self-injury (NSSI) is defined as the direct, deliberate destruction of one’s own body tissue without suicidal intent [
1] and includes behaviors such as cutting, burning, and hitting oneself. The risk for engaging in NSSI is particularly high in adolescence, in which the onset is consistently found to be around 14-years of age [
2,
3] and lifetime prevalence rates are about 17% in community samples [
4]. Engagement in NSSI is strongly associated with various adverse mental health outcomes such as low self-esteem, depression, anxiety, and suicide attempts [
5,
6]. Accordingly, it is unsurprising that the most common function of NSSI reported in non-clinical samples of adolescents is regulation of difficult and intense thoughts and feelings. Several recent studies [
7,
8] suggest that NSSI in adolescence is a predictor for depression, anxiety, and suicide attempts later in life. Taken together, NSSI represents an important public health concern for today’s youth.
In line with its functions, in the emotional cascade model [
9], NSSI is described as a result of a ruminative process (to an emotional stimulus) which results in a cascade which gradually increases emotional intensity and, ultimately leads to emotional dysregulation. The emotional cascade model asserts that NSSI serves as a form of distraction which temporarily reduces negative emotion and increases a perception of relief or even wellbeing. In this way NSSI represents a negative reinforcer in the emotion–behavior interaction. A more recent NSSI functional model, namely, the Cognitive-Emotional Model of NSSI [
10], suggests that a number of cognitive processes also play a role in this emotional cascade to reinforce the behaviour. Importantly, the new model underpins the complex associations between cognition, emotion and behavior at an individual level. In another conceptual model, Hooley and Franklin [
11] take into account some interpersonal factors (such as abuse/maltreatment/victimization and peer NSSI) in addition to the above factors. However, these interpersonal factors are only considered the level of triggers for NSSI. Notwithstanding the importance of these models, a conceptual framework to understand the interaction between NSSI and the environment is absent in current literature. The current paper presents a theoretical framework to understand the interaction between NSSI and the caregiver/adolescent relationship, which can be a first step to understand the interaction between NSSI within a broader context.
The interaction between NSSI and the caregiver–adolescent relationship
Beyond its well-documented effects on those who self-injure, NSSI also has a significant impact on entire (family) systems [
12‐
14]. After discovering a family member self-injures, most families experience acute stress and a sense of crisis. When caregivers find out about their child’s NSSI, they often feel overwhelmed and experience myriad emotions (e.g., anger, fear, guilt, confusion) [
12‐
15]. Indeed, the impact of NSSI on caregivers through secondary stress/distress, can disrupt family dynamics and impede family functioning [
16,
17].
In the (cross-sectional) studies examining the relation between NSSI and family processes to date, there exists a clear negative association between NSSI and a variety of family factors. For example, studies examining family functioning from the adolescent perspective, find that youth who self-injure report less emotional support, more criticism, and excessive behavioral control from family members [
18] when compared to youth who do not self-injure. Furthermore, adolescents who self-injure also report being less securely attached to their caregivers [
19]. Indeed, it is not uncommon for adolescents who self-injure to view their relationship with caregivers as unreliable and to believe that they may not be worthy of care. They also report difficulties integrating experiences across multiple levels of thinking and feeling (e.g., they may have a harder time adopting different perspectives), and difficulty forming reciprocal and empathic relationships with their caretakers [
20].
The negative association between a variety of family factors and NSSI found in cross-sectional (adolescent-reported) studies is often interpreted causally. However, in the context of longitudinal and multi-informant studies, a more nuanced interaction between NSSI and the family emerges. For example, findings from longitudinal studies [
12] show a dynamic and reciprocal pattern of influence between a child’s NSSI and parenting. Specifically, longitudinal research suggests that NSSI elicits more controlling (e.g., rule setting) parenting behaviors, which, in turn, is associated with more severe engagement in NSSI [
12]. To this end, NSSI seems to impact the whole family system and can push a family system into crises.
In multi-informant studies, extant literature suggests that having a child who self-injures has a clear, and often adverse, impact on caregivers [
14,
15,
21]. Indeed, researchers have suggested that managing care for a child who self-injures can result in “secondary stress” that is characterized by difficult thoughts and feelings (e.g., guilt, worry, or judgement) about the source of stress (such as a child who self-injures) or even oneself. This, in turn, can detrimentally impact daily life (e.g., logistical, emotional, attitudinal) [
22].
Having a child who engages in self-injury can raise particular challenges as it tends to be episodic and thus difficult to anticipate [
14]. As a result, caregivers of youth who self-injure often end up feeling overwhelmed or unable to manage their child’s needs [
14,
15]. This, in turn, can lead to “empathy burnout” in which a parent becomes increasingly unable to respond in a compassionate way [
23]. Chronic secondary stress can exacerbate self-injury duration and, in turn, reinforce negative family or parenting dynamics [
18,
24]. For example, in a qualitative study by McDonalds, O’Brien, and Jackson [
15], found that after NSSI was disclosed, mothers of children who self-injure reported high levels of perceived loneliness as well as fear of judgement by others in their peer groups (e.g. other mothers and fathers). Such feelings can inhibit reaching out to others, thereby increasing social isolation [
12,
14,
16].
Confusion about why a child self-injures (and general misunderstanding about NSSI) can also affect parents. For instance, caregivers report feelings of insecurity, guilt, shame and a sense of personal responsibility for the fact that their child self-injures [
12]. Furthermore, a lack of support coupled with a poor understanding of NSSI can hinder both the connection and effective communication with the child [
14,
18,
24]. Moreover, fear about future episodes of NSSI or a suicide attempt can be paralyzing for caregivers who feel like they are “walking on eggshells” in anticipation of a future negative event that they cannot predict or control [
15]. Finally, chronic emotional, social and practical (e.g., financial) strains can further compound the manner by which caregivers interact with and support their child [
25].
The aforementioned cascade of aversive feelings and self-appraisals, along with confusion about how to best respond to their child, may lead to hypervigilance and increased efforts to control their child [
12]. On the one hand, this control may be a way to deal with their own fear and insecurity. On the other hand, this may be perceived as intrusive by adolescents and may further strain family dynamics and increase the risk of NSSI [
3]. To date, this family dynamic cascade is not acknowledged or well described in current NSSI literature. To address this, we present “The NSSI Family Distress Cascade.”