Experiences of Unintentionally Severe Harm During Nonsuicidal Self‐Injury Among College Students

Engagement in nonsuicidal self‐injury (NSSI) is surprisingly common on college campuses (Gollust et al., 2008; Heath et al., 2008; Whitlock et al., 2006), with estimated prevalence rates ranging from 7% to 38.9% among college students (Cipriano et al., 2017; Gollust et al., 2008; Heath et al., 2008). According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), NSSI is defined as purposeful, self‐inflicted bodily harm that is expected to result in superficial or moderate damage to the skin. Importantly, however, researchers have found that the outcomes of NSSI do not always correspond with college students’ expectations for tissue damage. For example, Whitlock et al. (2011) found that 21.1% of undergraduate students who performed NSSI had inflicted more harm to themselves than intended. In another study assessing NSSI among university students, Buser et al. (2017) found a similar trend, in that 31.4% of participants who engaged in NSSI over the last 12 months had injured themselves more severely than intended.

These findings represent a significant challenge for college counselors. If students are at risk of harming themselves more severely than they intend during NSSI engagement, then college counselors must carefully consider physical safety concerns alongside their typical focus on psychological correlates of NSSI (Taliaferro & Muehlenkamp, 2015; Whitlock et al., 2006) and the impact of NSSI on academic performance (Kiekens et al., 2016). Unfortunately, little is known about the predictors of unintentionally severe injury during NSSI engagement—or the phenomenology of unintentionally severe injuries themselves. Researchers have attempted to uncover why some individuals injure themselves more severely than intended during NSSI engagement. Whitlock et al. (2011), for example, found that one in five individuals who injured themselves more severely than expected during NSSI had been using alcohol or drugs at the time of injury. Relatedly, in an earlier study, Whitlock et al. (2008) hypothesized that there may be distinct subsets of individuals who engage in NSSI. Using a latent class analysis procedure, the authors identified three subgroups of NSSI users, ranging from superficial severity to high severity. The high‐severity group—which was distinguished by its use of greater frequency of NSSI, a broader range of NSSI methods, and more dangerous methods—was 4 times more likely to inflict unintentionally severe injuries compared with individuals in the superficial‐severity and moderate‐severity groups. The high‐severity group was also more likely to perceive their engagement in NSSI as an addiction, have a history of suicidality, and report that “NSSI interferes with their life” (Whitlock et al., 2008, p. 730).

These results were in line with a report by Buser et al. (2017), in which college students who experienced an unintentionally severe injury during NSSI were more likely to experience addictive features of NSSI, compared with individuals who did not experience an unintentionally severe injury during NSSI. This result suggests that the addictive features of NSSI (e.g., difficulty reducing behavior despite presence of negative consequences, the need to engage more frequently or more severely to get the same effect, and increasingly more time spent on behavior) increase the risk of accidental injury.

Need for the Current Study

Taken together, previous researchers have found that increased severity of NSSI engagement (e.g., engagement in multiple methods and frequent engagement), addictive features of NSSI, and use of substances or alcohol during NSSI partially explain the occurrences of unintentionally severe injuries during NSSI among college students (Buser et al., 2017; Whitlock et al., 2008, 2011). Although these findings shed light on salient factors behind unintentionally severe injuries, the current body of research represents a very early stage of development. First, it is primarily quantitative in design. Thus, researchers have not been positioned to provide rich descriptions of the actual experiences of unintentionally severe injuries during NSSI. Details about clients’ subjective experiences of these injuries remain largely unreported in the research literature. Furthermore, the current line of research is limited in number and is just beginning to explore possible predictors of unintentionally severe injuries during NSSI. For example, in a regression analysis of multiple predictors (dissociation, impulsivity, and experiencing NSSI as an addiction) of unintentional injuries during NSSI, Buser et al. (2017) found only one significant predictor of unintentional injuries (specifically, experiencing NSSI as an addiction), and the effect size for this finding was relatively small. The small effect size suggested that other predictor variables may be more important in explaining variance in the outcome variable. Such limited empirical attention suggests that exploratory studies are particularly timely.

Qualitative investigations represent a valuable extension of this research, because they afford researchers the opportunity to explore and collect rich descriptions about experiences of unintentionally severe harm during NSSI. Researchers can use interview protocols and follow‐up questions to clarify the severity of these injuries and their contributing factors, thus informing college counselors about the phenomenology of these experiences and identifying a range of possible predictor variables not yet studied in quantitative investigations. The current study was designed to address this gap in the literature through a qualitative design. Specifically, we conducted in‐depth qualitative interviews with college students about experiences of injuring themselves more than intended during NSSI. We analyzed data with interpretative phenomenological analysis (IPA), a qualitative research method used to generate meaning from participants’ accounts of a given phenomenon. This method is described in detail below. Our overall research question for this investigation is as follows: “What is the experience of individuals who report unintentionally severe injury during NSSI?”

Method

Participants

We interviewed nine participants for this study. In our report of demographic information in this section, we restricted certain details to protect the confidentiality of participants. All participants were students at a private university in the northeastern United States. Participants ranged in age from 18 to 27 years (M = 21.56, SD = 2.51). Participants identified as female (n = 5, 55.6%) or male (n = 4, 44.4%). Most participants reported being in their junior year of undergraduate study (n = 6, 66.7%), and others reported being first‐year, senior, or graduate students. More than half of participants identified as Caucasian/White (n = 5, 55.6%), and others identified as Hispanic/Latino or multiethnic/multiracial. Most students identified as heterosexual (n = 7, 77.8%), and others identified as bisexual or pansexual. Most participants were not international students (n = 8, 88.9%). Most participants self‐reported an economic background of middle class (n = 5, 55.6%), and others reported backgrounds of lower class, working class, or upper middle class.

In the interviews, we asked participants about their history of NSSI, including age of onset and duration of NSSI behaviors. Participants reported that their NSSI started in childhood or adolescence. Most participants (n = 7, 77.8%) reported age of onset in adolescence, with an age range between 13 and 17 years. Two participants (22.2%) reported an earlier onset, with an age range between 7 and 12. A majority of the participants discussed a duration of NSSI between 2 and 4 years (n = 6, 66.7%), and three participants (33.3%) reported lengthier durations of NSSI (6 to 15 years).

Procedure

Upon receiving institutional review board approval, we recruited study participants by including an invitation for a research interview at the end of a separate quantitative survey. Individuals who volunteered to be interviewed for the present study were asked to provide their name and contact information for a follow‐up contact by a researcher. In addition, we posted our research invitation at two local mental health centers that serve mostly young adult women and at one college counseling center, but these methods of recruitment did not lead to any participants. We interviewed participants who were over the age of 18; reported a history of NSSI behavior; and indicated that, on at least one occasion, they unintentionally injured themselves more than expected during NSSI.

In an ongoing manner, we (all four authors) engaged in discussion of our positionality and assumptions related to this research topic. Two of the authors identified as female and two identified as male. All identified as heterosexual. Three authors identified as White, and one author identified as Middle Eastern. The first and third authors are graduate students in counseling at a program accredited by the Council for Accreditation of Counseling and Related Educational Programs; the second and fourth authors are counselor educators. The first three authors reported an assumption that the use of drugs or alcohol would be a common thread among stories of unintentionally severe injury during NSSI; they reported that this assumption may be influenced by previous NSSI and addiction research. The first author reported an assumption that unintentionally severe injury would be more common among individuals with increased pain tolerance. The third author commented on the likelihood of unintentional injuries being related to inexperience with NSSI; this author also noted that continued NSSI in the same body area may also contribute to unintended injury. The second author noted the potential relevance of dissociation during unintentionally severe injury, in addition to the use of NSSI to regulate affect. Finally, the fourth author commented on the potential for unintentionally severe injury to be comorbid with mental health issues and related to experiencing NSSI as an addiction.

Participants completed an informed consent form prior to the interview and were asked to pick a pseudonym to be used throughout the study and in its reporting to protect participant confidentiality. The first and second authors conducted the interviews, which were approximately 1 hour in duration. Participants chose phone (n = 2) or in‐person (n = 7) interviews. One participant who completed an in‐person interview also completed a follow‐up phone interview because of recording difficulties. The interviewers used a semistructured interview protocol throughout the interviews; they asked participants a range of questions but also welcomed ways in which participants could guide the interviews and allowed space for questions and directions that emerged during participant statements. Examples of questions from the semistructured research protocol were as follows: (a) Tell me about a time when you were engaging in NSSI and you unintentionally injured yourself; (b) Tell me about your experience of the injury; and (c) From your perspective, how do you understand what caused you to hurt yourself more severely than intended?

Data Analysis

In preparation for data analysis, the third author transcribed all interviews. We used IPA to analyze interview transcripts. We determined that a sample size of nine participants was appropriate for IPA, in view of precedent in the literature for this method of qualitative investigation (Bonavita et al., 2018; McManus et al., 2014; Williams et al., 2015) and recommendations of Smith et al. (2009). We outline our IPA procedures here as explicated by Smith and colleagues. When using IPA, researchers commit to awareness of and continual reflection on their potential biases and assumptions; this is done to limit influence of these biases and assumptions on data analysis. IPA is a qualitative method; when using this method, researchers are concerned with the specifics of participant experiences. Researchers invite participants to tell stories of their experiences and inquire as to how participants understand the experience.

In analyzing participant interview transcripts, we followed the guidelines of IPA and carried out an initial coding process in which we attended to three levels of analysis. The first three authors served as coders for this portion of the analysis and coded transcripts with descriptive comments, linguistic comments, and conceptual comments. Descriptive comments included codes relevant to key content issues shared by participants. Linguistic comments included codes pertinent to the language used by participants; such codes may attend to issues such as participants having difficulty selecting words, drawing on metaphors, and using words or phrases in a recurring manner. Conceptual comments included codes related to researcher interpretation of participant stories, such as questions about participant experiences and potential meanings beyond the surface content.

After coding each transcript for descriptive, linguistic, and conceptual comments, the first three authors formulated a list of emergent themes for each transcript. Smith et al. (2009) described themes in IPA as “an attempt to produce a concise and pithy statement of what was important in the various comments attached to a piece of a transcript . . . the themes reflect not only the participant's original words and thoughts but also the analyst's interpretation” (p. 92). The first three authors then reached consensus on the three levels of codes and the emergent themes for each transcript. As a next step, these authors identified commonalities among the emergent themes and agreed on a final list of themes. To reach consensus on the final list of themes, the first author compiled a list of all emergent themes across transcripts. The first three authors then engaged in lengthy discussions to pinpoint patterns across transcripts and identify a list of final themes endorsed by all three authors.

The fourth author served as the auditor for the study and carried out an independent audit of the data. This author read a subset of the uncoded data (n = 3 transcripts, 33.3% of data) and confirmed the original themes while also suggesting modifications. The first three authors reviewed the audit and, after discussion, made two changes: (a) modification of the name of one theme to capture participants’ experiences of reducing NSSI behavior and/or altering NSSI method after an unintentionally severe injury, and (b) adding a theme about self‐criticism after an unintentionally severe injury. Self‐criticism refers to the tendency to blame oneself for negative experiences and is typified in a statement such as, “This painful experience is my fault, on account of my stupidity.” (More description of this theme is provided in the Results section.) We then agreed on the final theme list, which is detailed in the Results section. After this final theme agreement, the first author contacted participants to conduct a member check. Four participants responded and indicated agreement with the themes; five participants did not respond to this member check.

Results

Explosive Affect Prior to Unintentionally Severe Injury

Most participants (eight out of nine participants) described experiencing intense negative affect prior to the unintentionally severe injury. Clement, for example, discussed the blend of anger, disappointment, and embarrassment that he felt before engaging in the unintentionally severe injury:

I was just very upset, I don't particularly remember something that I, something stupid to be honest, I don't remember what it particularly was, something that shouldn't have provoked the reaction that it did, but I was upset and disappointed with myself, and then I was upset and disappointed with myself for having gotten upset for something so trivial in the first place, and I was just very, very angry.

In this case, Clement found himself in a vicious cycle, feeling angry about a situation in his life and, in turn, feeling angrier that he allowed himself to be provoked by the situation. Similarly, Melissa stated that, prior to engaging in an unintentionally severe injury, she was “so full of anger and I didn't know how to cope with it.” Later, she characterized herself as “super angry” before engaging in NSSI. Like Clement's use of modifiers in describing his affect as “very, very angry,” Melissa signaled the intensity of her “super” affect. Likewise, Peter spoke to his intense affect before the unintentionally severe injury: “I got really upset and I thought, ‘I'll go cut my arm a little bit and make it sting, and that should shift my focus’ . . . and then I kind of got shaky a bit.” Later, he added that he was “just really freaking out and I felt nauseous.” Peter was so distraught that he experienced adverse physiological reactions as well. In sum, most participants identified intense negative affect as a precursor to the unintentionally severe injury.

Loss of Control During Unintentionally Severe Injury

When describing their unintentionally severe injury, most participants (eight out of nine participants) described a loss of control over NSSI engagement. This loss of control was associated with a lack of clear thinking and planning. In particular, the loss of control manifested in experiences of impulsivity or dissociation. Regarding impulsivity, participants described the spontaneity and urgency of their actions. They reported engaging in NSSI with little or no rational thought about the behavior and its consequences. For example, John linked his intense affect to the impulsive decision to engage in the unintentionally severe injury:

I'm overwhelmed with a flood of like emotions, whether they're angry, anxiety, like you know, upset, sad, like not feeling like I am myself, being lost in, I guess, a whirlwind and just acting instead of like being I guess thinking about it.

In his use of language, John distanced himself from agency over the behavior, saying that he was under the influence of intense affect and injuring without careful thought. Similarly, Rose began her unintentionally severe injury “not paying mind to it,” saying that she “didn't realize how fragile your skin is that you try to rip one little piece off and it will take off more than bargained.” Aaron, too, reported the lack of rational thought during the “moment” of his unintentionally severe injury: “I wasn't thinking. . . . In the moment you know I'm not thinking, ‘Oh, I'm going to use this other coping mechanism that I usually do, biting or hair pulling’”—methods which he characterized as more “measured” forms of NSSI. These participants attributed their loss of control to the decision to act quickly and without consideration of the behavior and potential outcomes.

Other participants described their lack of control as a dissociative experience. Ashley indicated that, during her unintentionally severe injury, she “blacked out a little because by the time I realized what happened, there was a lot more blood than I normally had.” Similarly, Melissa commented that her unintentionally severe injury was “like I wasn't there, like that wasn't me and then afterwards, I realized what I did and like I just did that to myself, I feel like I can't remember like parts of when I did it.” She went on to describe the injury as “an out‐of‐body experience because I really felt like I wasn't there.” Likewise, EK said that she “honestly blacked out” during her unintentionally severe injury, and CeCe reported that “I don't remember what I was doing, I just started picking at it without even noticing and it was more damaged than it already had. It started bleeding a bunch.” In these instances, participants felt as though they were personally absent from the unintentionally severe injury; they felt disconnected from their bodies and, in some cases, experienced amnesia about the event. Consequently, they lost control over their behavior.

Unfamiliar Method Associated With Unintentionally Severe Injury

Because it was a tool, because when I bite or hair pull, you know it doesn't hurt really. I know when you're biting eventually because you're doing it to yourself in a measured way, you will eventually just stop because you're like “Ow,” but also like the way I did it, it kind of like, I was doing it through a shirt and the shirt like ripped and I wasn't expecting the shirt to rip.

Aaron described that his decision to use a new tool resulted in a lack of precision, compared with the “measured” approach of biting. He found himself in the unusual experience of direct contact between his skin and the tool.

John also strayed from his usual use of a key and picked up a knife during his unintentionally severe injury. He stated,

This is a completely different tool that I'm not used to using and I'm just going to use it and I'll think like, “wait a minute, this is a different edge,” it's a different part of my body, you know, how wide is the cut, you know. I'm bleeding on the floor. . . . I didn't think about those things.

As John described it, he used a new NSSI method. He also cut himself on a different location of the body. These new experiences, in his estimation, were important ingredients in understanding the severity of his unintentional wound.

Well, definitely it had to do with the setting I was in. I didn't have my razors near me so that was like the closest thing, I didn't think I was going to hurt myself that much, like I just thought it would be quick and I left it there for more than I thought, and it turned out really bad.

In this case, Melissa felt an urgency to engage in NSSI. The only available instrument for self‐injury was an unfamiliar one, and her use of this instrument resulted in more injury than anticipated. Taken together, participants encountered unintentionally severe injuries as they replaced familiar NSSI methods with new ways of harming themselves.

Consequences of Unintentionally Severe Injury

Altered NSSI engagement after unintentionally severe injury. Most participants (eight out of nine participants) indicated that, after the unintentionally severe injury, they reduced engagement in NSSI or exercised more caution during NSSI engagement. In some cases, they ceased engagement in NSSI altogether. Melissa, for example, was compelled to visit a psychiatrist after her unintentionally severe injury. This experience led her to completely cease engaging in NSSI:

The only thing that stopped it was because I had to go to the psychiatrist; that scared me, the pills that he gave me, they scared me, and I just stopped because I didn't want to be like a zombie anymore, so like, if I were not to get the help that I needed, I would still be doing it today.

Similarly, Aaron spoke about reducing his engagement in NSSI after the unintentionally severe injury: “I have had a couple of very stressful situations, but I don't use tools anymore, really. . . . I don't want like to get an infection from using a tool or having more pain.” Although he did not completely cease the behavior, Aaron decided to stop using tools for NSSI and to avoid serious consequences, such as infection. EK, too, stated that she was “way more careful” after the unintentionally severe injury. As she reported,

I mean, like, I would, after that, I can't go into this fully fresh out of the rage. I can't do that anymore because I was terrified of something bad happening. So I would like punch a pillow or, like, that's when I started running.

In EK's case, she was frightened by the unintentionally severe injury and turned to safer coping mechanisms, such as punching a soft pillow or exercising.

Self‐criticism about unintentionally severe injury. Alongside their decisions to alter engagement in NSSI, all participants discussed feelings of regret, embarrassment, and/or shame after the unintentionally severe injury. These feelings were mainly due to scars from the injury or other outcomes, such as having a parent or friend discover their use of NSSI. Clement shared, “I did feel foolish, of course, afterwards, after the anxiety. After I was able to clean everything up and then the anxiety subsided, then I felt foolish and ashamed of myself for having done what I did.” Peter also reported self‐criticism after the unintentionally severe injury, stating that “It was mainly me telling myself that I was an idiot and I did that every time, but this time it was more like, ‘Why did I do that?’ . . . Like this was really stupid.” EK similarly rebuked herself for the unintentionally severe injury. After seeing that she harmed herself more than expected, she told herself, “This is your fault. Look what you did. You couldn't even do it right.” Because her NSSI engagement did not go as planned, she experienced another opportunity for self‐criticism. In such ways, participants encountered negative affect after the unintentionally severe injury.

Discussion

In this study, we examined college students who engaged in NSSI and experienced unintentionally severe injury. Through qualitative analysis, we identified the following major themes: (a) explosive affect prior to unintentionally severe injury; (b) loss of control during unintentionally severe injury; (c) unfamiliar method associated with unintentionally severe injury; and (d) consequences of unintentionally severe injury, specifically involving changes in emotional states and participants’ use of NSSI.

The first theme pertained to intense negative affect experienced by participants prior to the unintentionally severe injury. Specifically, participants reported feelings of intense anger, embarrassment, or disappointment immediately before engaging in the unintentionally severe injury. To date, researchers have not correlated negative affect with unintentionally severe injuries during NSSI. Previous researchers have shown that the urge to engage in NSSI often occurs during states of high negative affect (Bresin et al., 2013; Chapman et al., 2006; Nock et al., 2009). Moreover, researchers have documented that participants’ inability to manage intense emotions affects the method used during self‐injury. Specifically, Kleiman et al. (2015) found that aggressive methods of NSSI, such as hitting, were more common among individuals who exhibited trait aggression, compared with those who were not aggressive. Our findings extended this literature by indicating that intense negative affect may also be a predictor of unintentionally severe injuries during NSSI engagement.

Loss of control, the second main theme, manifested itself in a variety of ways, including participants’ impulsive and dissociative experiences. In the literature on impulsivity, authors have pointed to negative urgency and lack of premeditation as primary factors affecting decision‐making and emotional response in individuals who engage in NSSI (Bresin et al., 2013; Glenn & Klonsky, 2010; Hamza et al., 2015; Maxfield & Pepper, 2018). Among most of our participants, impulsive behavior involved a lack of rational thought during NSSI engagement and the resulting loss of control. Relatedly, participants discussed dissociative experiences during the unintentionally severe injury; they felt as though they were not present during the injury and/or did not realize what they were doing. In previous studies on dissociation and NSSI, researchers have found that dissociation can function as a form of experiential avoidance to block out distressing experiences (Chapman et al., 2006; Swannell et al., 2012). The apparent lack of clear decision‐making and rational thought among our participants ties into previous findings that individuals who engage in NSSI display poor inhibitory control when compared with individuals who do not self‐injure (Allen & Hooley, 2015).

As for the use of unfamiliar methods, our third theme, most participants discussed how the unintentionally severe injury occurred when they deviated from their normal routine for NSSI. The change in routine included the use of a new way of inflicting NSSI (e.g., using a tool for the first time) and injuring tissue in a different part of the body than usual. The findings correspond to research on addictive processes in NSSI engagement. For example, Buser et al. (2017) found that individuals who experience NSSI as an addiction tend to be at higher risk for unintentionally severe injury. It may be, for example, that such individuals develop tolerance to the behavior over time and try a new method (e.g., harming themselves more frequently or more deeply) in order to achieve the same function.

The final theme concerned the consequences of unintentional injury. These consequences included the reduction or cessation of NSSI after the unintentional injury. In some cases, participants exercised more caution by using less severe methods or avoiding certain body sites when engaging in NSSI. The alterations are an encouraging finding, because experiencing an incident of unintentionally severe injury seemed to have reduced NSSI frequency among participants. One reason may be that participants’ NSSI engagement was revealed to others (e.g., medical doctors); it may be that self‐disclosure of NSSI engagement and social pressure curbed incidents of NSSI. Similarly, Buser et al. (2014) found social support to be beneficial in reducing NSSI engagement after participants’ self‐disclosure of NSSI, and Kiekens et al. (2017) found that social relationships may counter negative self‐beliefs in individuals and lead to reductions in NSSI engagement.

Moreover, most of our participants disclosed feelings of regret, embarrassment, and/or shame as a consequence of unintentionally severe injury. Deliberto and Nock (2008) pointed to a similar pattern; they found that the desire to stop NSSI behavior may be due to “unwanted attention from others, to prevent scarring, because of shame caused from engaging in NSSI, and because their NSSI upset family and friends” (p. 229). Thus, our findings align well with other researchers who have also observed participants’ sense of shame after NSSI engagement.

Strengths and Limitations

The study has several strengths. In particular, the use of an auditor, member checking, and ongoing reflection on our own biases supported the trustworthiness of our results. Another strength of this study is that participants represented diverse identities in terms of gender, race, sexual orientation, and economic background. Additionally, the design and focus of the study addressed a gap in the research. Relatively little is known about the causes and experiences of unintentionally severe injuries during NSSI. By carrying out a qualitative study on this topic, we gathered rich data about the nuances of unintentionally severe injuries.

The study also has important limitations. The participants often reflected on past engagement of NSSI rather than current experiences. This can result in recall bias in that crucial details may have been lost or not remembered by participants. Additionally, we interviewed college students, and our results may not accurately reflect unintentionally severe injury experiences of individuals from different age groups and noncollege populations (Muehlenkamp et al., 2013; Whitlock et al., 2011).

Implications for College Counselors

Given that explosive affect was reported by college students prior to unintentionally severe injury in the present study, it may be beneficial for college counselors to prioritize emotional regulation skill training for college students who engage in NSSI. Similarly, Turnage‐Butterbaugh (2014) reviewed the NSSI treatment literature and suggested that an important goal of therapy with college students who perform NSSI is to encourage them to develop a repertoire of stress management skills. Mindfulness‐based cognitive behavior therapy, for example, is one method for promoting emotional regulation (Chapman et al., 2006; Hofmann & Asmundson, 2008). Meta‐analyses have supported the use of dialectical behavior therapy (DBT) in treating adolescents who engage in NSSI (Cook & Gorraiz, 2016; Ougrin et al., 2015). This therapeutic model features a strong emphasis on managing emotional dysregulation. For example, DBT teaches distress tolerance skills by using the ACCEPTS (activities, contributing, comparisons, emotions, pushing away, thoughts, and sensations) strategy for clients to use as a distraction technique in times of distress (Linehan, 2015). “Sensations,” for example, refers to taking a hot shower or holding ice in your hands to distract from a negative emotional experience.

Dissociative experiences were also reported by participants in the present study as an experience associated with unintentionally severe injury. Navarro‐Haro et al. (2015) argued that cognitive reappraisal—a cognitive tool that is used to reevaluate situations that are likely to bring on negative emotions—may be a helpful skill for attenuating NSSI engagement in individuals with a history of dissociation. Navarro‐Haro et al.'s study sampled participants who engaged in NSSI as a feature of borderline personality disorders and comorbid eating disorders. The authors found that, for participants with higher levels of cognitive reappraisal, NSSI decreased even though they continued to experience dissociation. In particular, the authors suggested that one of DBT's skills, “checking the facts” (Linehan, (2015, p. 407), can be used as a strategy for cognitive reappraisal. For example, Navarro‐Haro et al. (2015) stated that “DBT skills are designed to help patients to stop experientially avoiding undesired internal experiences and to change the emotional reactions by checking the facts of the emotional event” (p. 129).

Last, because many participants mentioned that unintentionally severe injury resulted from utilizing an unfamiliar method, a harm reduction approach could also be suggested. In this way, counselors help clients stay safe during NSSI engagement by using familiar methods and tools (Inckle, 2011). Practitioners who use this approach with clients who engage in NSSI reported reductions in both intensity and severity of NSSI among clients (James et al., 2017). Counselors can also teach clients safer alternatives to NSSI, such as having clients wear and snap rubber bands on wrists, draw on body sites with markers, and place their hands in cold water (Kilburn & Whitlock, 2009). Safer alternatives to NSSI may reduce the likelihood that clients will pursue unfamiliar methods when urges to perform NSSI arise.

Areas for Future Research

This study is one of the first qualitative investigations of unintentionally severe injury during NSSI. Future researchers could extend our results through a quantitative study on variables reported by our participants. For example, researchers could examine in more detail the dissociative and impulsive experiences related to unintentionally severe injury during NSSI. Dissociative experiences reported in our study occurred during unintentionally severe injury rather than preceding self‐harm, so future inquiries could examine when and how dissociation occurs during unintentionally severe injury. Given that some participants in our study experienced dissociation and others reported impulsivity, future researchers might want to investigate predictors of these experiences among individuals who engage in NSSI. Finally, because participants reported that unfamiliar methods were associated with their unintentionally severe injury, it would be interesting to study individuals’ first experiences with NSSI; presumably, any method would be unfamiliar at first use. It could be that rates of unintentionally severe injury are particularly high during onset of NSSI.