Non-Suicidal Self-Injury (NSSI): Interview with Jennifer Muehlenkamp, Ph.D.

Today’s Social Work Podcast looks at the issue of non-suicidal self injury, or NSSI. According to the International Society for the Study of Self-Injury, NSSI is the intentional destruction of body tissue without suicidal intent and for purposes not socially sanctioned. I spoke with Jennifer Muehlenkamp, Ph.D., associate professor at the University of Wisconsin - Eau Claire, and one of the world’s leading experts in NSSI. In today’s episode, Jennifer and I talked about the definition of NSSI,  the intersection between suicidal and non-suicidal self-injury, and some things that clinicians should and should not do when working with clients who self-injure. We ended our conversation with some speculation on the future of NSSI as a stand-alone psychiatric disorder in the DSM-5.

Download MP3 [25:55]



Bio
Jennifer Muehlenkamp, PhD, is a clinical psychologist and assistant professor at UW-Eau Claire. She earned her Ph.D. from Northern Illinois University in 2005. Dr. Muehlenkamp specializes in understanding and preventing suicidal and non-suicidal self-injury in youth. She has published over 60 peer-reviewed articles and book chapters on self-injury and suicide in adolescents and college students, some of which have informed the non-suicidal self-injury diagnostic category for DSM-V. Dr. Muehlenkamp has assisted with the creation and evaluation of the Signs of Self-Injury Prevention Program, is a founding member of the International Society for the Study of Self-Injury, and co-author of a treatment book titled Non-Suicidal Self-Injury that is part of the Advances in Psychotherapy Series. Dr. Muehlenkamp’s research and clinical guidelines are internationally recognized and have earned awards frm the American Association of Suicidology.

TRANSCRIPT

Introduction
Jonathan Singer: Today’s Social Work Podcast looks at the issue of non-suicidal self-injury, or NSSI. NSSI is a hot topic among clinicians / psychotherapists, but this wasn’t always the case. Twenty or thirty years ago, the only folks talking about NSSI (alternately refered to as Self-Injurious Behavior, or Deliberate Self Harm) were those who worked with Borderline Personality Disorder. This was, in part, because BPD is the only DSM-IV-TR diagnosis that includes NSSI as a symptom. In fact, self-harm became a red-flag for BPD; if you had a client who engaged in NSSI, you’d start with the assumption that he or she had borderline personality disorder.

But times have changed. While cutting, burning, or other forms of self-injury is more common among people with psychiatric diagnoses (Klonsky & Muehlenkamp, 2007), the presence of NSSI no longer implies an Axis II diagnosis – or any diagnosis at all. A 2011 study by David Klonsky found that nearly 6% of adults in the USA reported a lifetime history of NSSI. For US adults under the age of 30 it was 19%. Interestingly, a 2012 study by today’s guest, Jennifer Muehlenkamp and her colleagues, found that the international prevalence of NSSI among adolescents was 18% - nearly the same as in US adolescents. For reasons that are not clear, NSSI has moved from being a symptom of a serious personality disorder to a coping mechanism used by nearly 1 in 5 adolescents. So, NSSI has become a hot topic in recent years in part because it is showing up in the general population, rather than just a small sub-group of psychiatric patients.

This change in WHO engages in NSSI has also renewed interest in the question of WHY people engage in NSSI. Are people who self-injure numb and trying to feel something, or are they feeling too much - overwhelmed by their emotions – and trying to feel less?  Is self-injury a pathway towards or pathway away from suicide? In the late 1930s, Karl Menninger suggested that self-injurious behavior was a way to “avert suicide” (Muehlenkamp, 2005). I’ve had a couple of clients for whom that description is accurate. I remember this one teenager who told me that he would try everything to get suicidal thoughts out of his mind. As a last resort, when nothing else helped, he’d cut himself – not to die, but to get rid of the ideation. He siad it worked every time. One non-lethal cut that would draw a small amount of blood, and the ideation would be gone – sometimes for up to a month. The thing that was so fascinating to me was that he only engaged in NSSI when he was overwhelmed by thoughts of killing himself. So, Menninger’s hypothesis fits this kid. But, it doesn’t seem to fit for everyone. In fact, research has suggested that the youth who say they engage in NSSI and have thoughts of suicide are at higher risk of attempting suicide than youth who report suicidal ideation or NSSI alone (Claes et al, 2010).  So, for the clinician who works with people who self-injure, understanding the purpose and the meaning of the self-injury, the risk posed by the self-injury, and how to best address it, are all issues that need to be worked out.

If all of this makes NSSI sound complicated, it’s because it is. That’s one of the reasons I spoke with  Jennifer Muehlenkamp, associate professor at the University of Wisconsin – Eau Claire, and one of the world’s leading experts in NSSI.

In today’s episode, Jennifer and I talked about the definition of NSSI,  the intersection between suicidal and non-suicidal self-injury, and some things that clinicians should and should not do when working with clients who self-injure. We ended our conversation with some speculation on the future of NSSI as a stand-alone psychiatric disorder in the DSM-5.

Jennifer and I spoke in April 2012 at the American Association of Suicidology conference. I cornered her as she was waiting for an elevator in between conference sessions and asked her if she’d be willing to talk about NSSI for the podcast. Now, we don’t really know each other. Without batting an eyelash, and without any prep time, she agreed and we had the conversation you’re about to hear. During our conversation she never once mentioned that she was at the conference in part to receive one of the most prestigious awards in the field of suicidology: the Schneidman Award for outstanding contributions in research in the field of suicidology by an early stage investigator (click here to see a copy of Jennifer and her award: http://suicidology.smugmug.com/Other/45th-Annual-Conference-Day-3/i-SC3TR7c/0/Ti/DSC3788-Ti.jpg). Her generosity extended beyond the interview: She put together an outstanding list of scholarly books, peer-review journal articles, and memoir about NSSI that you can find on the Social Work Podcast website. after I returned from the conference, my colleagues over at the Living Proof Podcast published a wonderful episode on NSSI with one of Jennifer’s colleauges, Janis Whitlock.

So, without further ado, on to Episode 73 of the Social Work Podcast: Non-suicidal Self-injury: Interview with Jennifer Muehlenkamp.

Interview
Jonathan Singer:  Jennifer, thanks so much for being here and talking with us on The Social Work Podcast about non-suicidal self-injury.  The first question is what, is non-suicidal self-injury?

Jennifer Muehlenkamp:  Well, non-suicidal self-injury is a behavior and the way we define it in the field right now is that it's the deliberate or the intentional destruction of body tissue without suicidal intent and the behavior is not done for socially approved reasons. So that means things like tattooing and body piercing do not count as self-injury.  And so, self-injury, another key piece to it is that with it being bodily tissue damage, it means that the damage is immediate.  So sometimes people will ask me “so is binge drinking and disordered eating - are those examples of self-injury?” And we consider those indirect forms of general self harm because non-suicidal self-injury actually results in immediate tissue damage.

Jonathan Singer:  So, like, somebody burning themselves with a cigarette or cutting themselves with a knife?

Jennifer Muehlenkamp:  Yes, exactly.  And what we find is that cutting is one of the most common behaviors particularly among adolescents, particularly among young adult females whereas things such as intentional banging or punching objects in order to induce a bruise, banging behaviors are more common in males as well as the punching and the banging might be taking one’s, let's say wrist, and slamming against the side of a table or slamming it against the side of a wall or something like that a few times in order to get a bruise to create some kind of sensation.  I had one client who would not only cut himself which is a little bit different for males, but not only cut himself, but when he get really upset is that he would take his fist and he would bang it on the corner of his desk at school and he would do it probably five or six times.  He said it felt numb and kind of tingly and then he would be done.

Jonathan Singer:  So clearly that’s self-injury and it's not suicidal, like you can't kill yourself by, you know, banging your fist against the side of a desk, right? So clearly that’s non-suicidal. But if you were working with somebody who came in and had, you know, cut marks on their arm, like, how would you know that that’s non-suicidal self-injury?

Jennifer Muehlenkamp:  That’s a really good question.  One of the first things you really need to do right is ask people because we know that most adolescents and young adults, the people who engage in this behavior will be upfront and say no, I'm not trying to kill myself.  They often engage in this behavior to cope with their distress. And it helps them cope with emotions. And some of the key emotions that they face are things like anger and anxiety.  A lot of them will say that they engage in this behavior sometimes to punish themselves because they don’t think they're worthy or they did something wrong.  And so if you ask them in a gentle way kind of around the line of you know, “so tell me what does self-injury do for you,” “like how does this behavior help you?” then you'll first break down some barriers and get someone to be more willing to take to you about it, but then you'll also get to see it.

And then you can just ask them, you know, “were you wanting to die from this?  Did you want to kill yourself as a result of this behavior?”  And they’ll often tell you no.  The other thing is that we know that people who die from suicide or who make very little suicide attempts often do not do so through cutting, which I think a lot of people are very concerned about because cutting is potentially very damaging and you can have very severe wounds, but it's very hard and it's very rare to die from cutting.  And so, of those individuals who do engage in self-injury and very severe self-injury who do make a suicide attempt oftentimes the attempt is through a different means or a different method than what the self-injury was.  So, the first step is really to ask them about their intent and what the behavior does for them.

Jonathan Singer:  So really if somebody comes in and I see that they’ve got cut marks on their arm, I could of course gently, right with rapport and do all this therapeutic things that we do, but eventually get around to saying so I noticed that you have cut marks on your arm, you know, what were you intending to do, something like that, right?

Jennifer Muehlenkamp:  Mm-hmm.  Yeah.

Jonathan Singer:  So, you know, one of the things that I've heard about cutters (right - this is a generic term for non-suicidal self-injuries, kids who cut but don’t want to die), is that they cut because the pain of the cutting is something that they can deal with, but the pain inside is something that they can't.  So, it's sort of like it transfers the pain.  Is that right?  I mean is that, you know, that’s what I've heard on the street kind of thing from other therapists, but I guess my question is why do people engage in NSSI?

Jennifer Muehlenkamp:  What we're finding in the research there's a lot of reasons why people engage in self-injury and what you said and what you described is I would say somewhat accurate.  So, there are a lot of people and what we know is that the emotional state right before an act to self-injury is often one of intolerable distress. And like we said oftentimes very negative emotions, intense emotions. Sadness is not real common. A lot of people are like “oh, they're so depressed and that’s why they do it.” No. What the research shows is it's more of the high tension, high arousal kind of negative emotion, so the anger, the anxiety, the frustration and what we find is that the kids and the people who engage in this behavior just can't – they find it very overwhelming. And so engaging in the behavior not only produces a little bit of relief, but it also kind of gives them an immediate solution.  And I know to people who don’t engage in the behavior, that can seem sort of bizarre, but we also know physiologically what happens when you get a wound is that not only do you have a release of endorphins in your body which are feel good chemicals, but we also get a release of cortisol which helps us to focus our attention.  So, some people will also engage in the behavior because things seems so out of control, they don’t know how to problem solve, self-injury actually calms them down and they can now focus and actually maybe then start to engage in more adaptive problem solving.

So, sometimes it is to externalize the pain.  I had one client who would talk about how she would feel so numb inside that she would self-injure in order to feel pain to remind herself that she is alive and she is a person. But a lot of the clients that I work with it was really more along the lines of “let me kind of get rid of this negative emotion right away,” so kind of that immediate gratification so “then I can move on” rather than kind of riding out the slower tide of emotions that we need to let dissipate.

Jonathan Singer:  Do you find that kids who start out cutting or doing some other sort of NSSI–

Jennifer Muehlenkamp:  It's a hard term [laughing]

Jonathan Singer:  [lauging] It is.  It is.  – go on to become suicidal?  Like is there a trajectory?  Because I know that’s something that parents and sort of the general public is concerned about.

Jennifer Muehlenkamp:  Sure.  And what I can say is that it's good to be concerned and if you're working with someone who’s engaging in self-injury to ask them periodically. And what you want to do is ask them about warning signs that you see if they start to feel more hopeless, pull away from people.  So, if you see basic suicide warning signs, be concerned.  With that said, there's a large portion of adolescents who engage in this behavior who are never suicidal.  We don’t have great longitudinal studies.  Of the cross-sectional studies we have, which means that you study kind of one group in time and then you ask them, you know, “when did you start self injuring?  If you’ve attempted suicide when did you attempt suicide?”

What we find is the age at which they engage in self-injury tends to be significantly younger than the age at which they make their first suicide attempt.  So, that would suggest that self-injury might lead into suicidal behavior if they get to a suicidal state.  I know of one longitudinal study in college students, which I happen to be involved in, that we did find longitudinally over a three-year period that of the college students who engage in 20 or more acts of self-injury in their lifetime that that predicted over a three-year time period who is likely to engage in either making a suicidal plan or attempting suicide.

And so there is a predictive relationship there, but what we often see is that things get a lot worse for the individual. And anecdotally, so I'm still trying to find data for it, but one of the things I've heard clinically is that when self-injury doesn’t work anymore for the individual.  That’s when I’d be most concerned because that’s their coping strategy and if it's not working anymore, they're going to get to that ultimate desperation and become more suicidal.

Jonathan Singer:  So, when you have somebody that engages in NSSI as a coping strategy - you know, [NSSI as] maybe the first step in problem solving as you were describing earlier - what are some things to do with that client to help them to develop maybe better coping skills rather than self-injurious behavior? Rr do you say self-injurious behavior is not really that bad if it helps them do what they need to do and move on?

Jennifer Muehlenkamp:  Mm-hmm. I think you're raising a fundamental question that goes back to all kinds of dysfunctional behaviors, so at what point do we really need to intervene, when is it a problem and so on.

Jonathan Singer:  Sort of abstinence versus harm reduction–

Jennifer Muehlenkamp:  Right.

Jonathan Singer:  But yeah.

Jennifer Muehlenkamp:  Right.  And  I know there are some people in Australia who are really advocating a harm reduction model which I find interesting.  I'm kind of in the camp that suggests that self-injury is a pretty – I don’t want to say – it's not really invasive.  It can be, but it's a pretty extreme behavior for coping and so generally what I recommend clinically is one of the first things you can do is not immediately ask the person to stop.  It's really unsettling as a clinician, as a parent, as a friend to watch someone intentionally, right cut themselves, burn themselves, you know, do something very damaging, but what's really important is to first recognize that it is their coping strategy.

So, just like if you go home and what your coping strategy is just to take a nice warm shower, right or to kick back and you know, watch Family Guy (http://en.wikipedia.org/wiki/Family_Guy) or whatever it might be, right and suddenly you say – your therapist says you can't watch Family Guy anymore, right.  You can't take a warm shower, you're going to either stop therapy or things are not going to go well for you. 

So, what you want to do is start gradually, and you can use some of the basic kind of behavioral strategies to start to address you know their thoughts that they might be having to help them think about what other things could you do. Where I often start to be honest, is to work on delaying. And so not, you know,  means removal and not means restriction, but basically start with delay. “Can you engage and try some of these other behaviors, coping strategies first and you know, start with one and if that doesn’t work then maybe you can self-injure,” then you extend that, right?  So, then there are two or three things. And then if that doesn’t work, you’ve got your self-injury. So you slowly kind of build the steps away from the self-injury and let them see that the other things do work if you give them time.

Another strategy that I've used and I can tell you about, I've used it with two clients pretty successfully. And there's a one client that really comes mind who had engaged in very very severe self-injury for many years and she wasn’t – we were at the point where we were talking about, you know, “are you willing to get rid of your razor blades or not?” And she said no. And so I respected that. But what we did is we took her razor blades and we put them inside, basically a coping box is what we call them, and she had a box of things where she had picture of her sisters, pictures of friends, notes that when she was doing good, that she would write to herself to remind herself about what's good. So, we put all those things in there and that she also put the box in the back of her closet where she told me was really messy and so in order – when she would get really distressed and want to cut herself, she would have to go to the closet, dig to the back to pull a box out and then she would encounter all those pictures, her positive coping statements and things like that that would make her think about more of the long term consequences of the self-injury because she was committed to not engaging in the self-injury and that really was a huge step for her and really worked well for her.

Jonathan Singer:  That’s amazing.  You know in terms of suicide prevention, I'm thinking of the – what they did in England about making Tylenol only available in bubble packs.

Jennifer Muehlenkamp:  Right.

Jonathan Singer:  You know, if you have to pop one out, each one out, it's very different than opening up a bottle.  Like if you have to go at the back of a messy closet and dig out a box to get your razor blades, just probably that time delay was an important way to do some delaying–

Jennifer Muehlenkamp:  Yeah.

Jonathan Singer:  – as you said.

Jennifer Muehlenkamp:  Yeah.  I think so and I think another big part of it is that she was very connected to her family and friends in wanting to make a difference. And so I think if you can find that long term goal that a client is really striving to and make it immediately salient to them - because a lot of times people who self-injure are so focused on the immediate distress that they put off their long term goal for the immediate distress relief - that if you can bring that long term goal to the immediate, you're also more likely to then trigger adaptive problem solving and kind of promote more of a delayed gratification so to speak.

Jonathan Singer:  So, non-suicidal self-injury is defined by being not suicidal, right –

Jennifer Muehlenkamp:  Mm-hmm.

Jonathan Singer:  and is that something that people are talking about in terms of like the terminology or would it – how it sort of defines the behaviors by what it's not.  And I guess a bigger question, is there any move to make non-suicidal self-injury like its own disorder, diagnosis like anything like that?  Is anything coming down the pike?

Jennifer Muehlenkamp:  Yes.  In fact, if anyone has been sort of following the APA or the American Psychiatric Association’s revision of the DSM-5, what you'll see and it has been somewhat of a controversial discussion is that they are proposing a non-suicidal self-injury disorder for DSM-5, and it is primarily based on the fact that this is a behavior distinct from suicide that could be its own risk factor for suicide, and that we see this behavior in many people who do not meet diagnostic criteria for borderline personality disorder which is what the behavior is commonly been associated with and in fact the highest rates where you see this behavior in terms of the disorder is actually among individuals with bulimia nervosa. And so eating disorders have the highest rate of self-injury as well as individuals who are suffering from post traumatic stress disorder or PTSD as well as some of the depression on the other anxiety disorders. 

So, the behavior is definitely defined by what it's not and that’s a key debate that’s out there in the field as far as – because we know suicidal behavior often is associated with ambivalent intent, fluctuating intent, one minute you want to die, the next minute you don’t and there are some people who do describe that during their acts of self-injury, they might have a fleeting thought about suicide, but the behavior was not engaged in with the intent to die, so it adds a lot ambiguity. And so I think that’s where as a clinician, it's really important to talk with your clients and to even ask them “at any point in your self-injury did thoughts of suicide come up?” And if they say “yes,” then that’s a doorway to ask well how strong were they, right so that you can kind of monitor for it without I guess negating the fact that the individual saying I'm not suicidal, right, but you can still do your assessment in that way.

I think with the potential for the non-suicidal self-injury disorder to come to fruition is that clinicians will be able to hopefully get some more precise training on it, to start to look at the behavior as a behavioral problem because a lot of the treatments that we have out there work with behavioral methods to reduce the behavior and once we have an identified disorder and it's not wrapped up in another stigmatized disorder, we can I think be more effective in both our treatment and our prevention.

Jonathan Singer:  So, are there any other things that clinicians should think about or know about, be aware of with regards with folks who engage in NSSI?

Jennifer Muehlenkamp:  I think there are probably a couple of other things that come to mind that I've been asked before by clinicians.  One is that a lot of times clinicians ask me “well, if I'm disgusted by the behavior or I find the behavior hard to deal with or just hard to understand, what should I do?” Because sometimes it's hard to hold back your visceral reaction to things and I think the first thing to recognize is that those are common responses that people will have and it's also the time where you want to do, you know, kind of put on your clinical face, right and do the best you can to internally monitor recognize that that’s your reaction and then also recognize that individuals who are sharing this behavior detect those, you know, kind of subtle reactions and so they’ll really pull back if they think you're scared or it's too much or your disgusted by it.

So, one of the things we really recommend is that the way you ask about the behavior, after you ask about it, inquire a little bit more from their perspective saying, you know, “oh, you know, that surprises me about you.” If you're really shocked by it and then ask them to explain more about the behavior for them, so to find a gentle way to enter into it.  The other thing that I'm almost always asked is “should I look at the wounds?”  And I will tell you there is some debate in the field about whether or not you should.  I think I'm a majority of people say do not look at the wounds and there's a couple of reasons for that.  One is –well, first of all, if it's a place that they're injuring that’s inappropriate, you have to not look at it, right.  It's inappropriate you don’t want to–

Jonathan Singer:  I'm cutting on the inside of my leg, right, yeah. [laughing]

Jennifer Muehlenkamp:  [lauging] Right, yeah.  So, don’t look at it.  The other part is that if it's, you know, forearms, calves and things like that that are easy is that for some people they believe if you look at it, you might inadvertently reinforce the behavior because for some people they use it as a signal to others to say I'm in a lot of distress, help me out.  And so, as a therapist, if that’s the way you communicate about the self-injury, you might actually increase the self-injury because that’s how they’ll tell you about their distress instead of learning their emotion words.

And the other thing is that if you're worried about the severity, I just ask my clients to report.  So, I'll ask my client who says, you know, “I cut myself the other day and I think it was pretty bad.” And so I'm not a medical provider and they know that upfront.  And I'll say “I'm not a medical provider, but can you tell me, you know, how badly did it bleed?  Was there a big gap, you know, did it actually stop bleeding and you could see tissue underneath?”  I had one client who cut so deeply to the point where it actually stopped bleeding and so she was in the next day fortunately and I said “you need to go to the emergency department to get stitches. I'm pretty sure.” And so just asking things about that or if they burn themselves.  You know, are you getting blisters, is it oozing like that kind of stuff just to get a basic assessment and then know if you have to refer him to a medical provider.

Jonathan Singer:  Such great information.  Jennifer, thank you so much for taking the time to talk with us today about non-suicidal self-injury.  I really appreciate it.

Jennifer Muehlenkamp:  Yeah.  Well, thank you.  I really enjoyed talking to you.

~ End of Interview ~

---

Recommended Books
Klonsky, E.D., Muehlenkamp, J. J., Lewis, S., & Walsh, B.W. (2011). Advances in Psychotherapy: Nonsuicidal Self-Injury. Hogrefe Press.

Nixon, M.K. & Heath, N.L. (2008). Self-injury in youth. New York: Routledge.

Nock, M.K. (Ed.). (2009). Understanding nonsuicidal self-injury: Origins, assessment and treatment. Washington, DC: APA.

Hollander, M. (2008). Helping teens who cut. New York: Guilford.

Gratz, K.L. & Chapman, A.L. (2009). Freedom from self-harm: Overcoming self-injury with skills from DBT and other treatments. Oakland, CA: New Harbinger.

Walsh, B. (2012). Treating self-injury: A practical guide. New York: Guilford.

Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007).  Dialectical  behavior therapy with suicidal adolescents.  New York: Guilford Press.

Joiner. T. (2007). Why people die by suicide. Cambridge, MA: Harvard University Press.

Peer-Review Journal Articles
Muehlenkamp, J. J.  (in press). Body regard in non-suicidal self-injury: Theoretical explanations and treatment decisions. Journal of Cognitive Psychotherapy.

Muehlenkamp, J.J. & Kerr, P.L. (February 2010). Untangling a complex web: How non-suicidal self-injury and suicide attempts differ. The Prevention Researcher, 17(1), 8-10.

Muehlenkamp, J. J. (2006). Empirically supported treatments and general therapy guidelines for non-suicidal self-injury. Journal of Mental Health Counseling, 28, 166-185. 

Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health, 6(1), 1 - 9. doi:10.1186/1753-2000-6-10 

Klonsky, E.D. (2011). Non-suicidal self-injury in United States adults: Prevalence, sociodemographics, topography, and functions. Psychological Medicine, 41, 1981-1986. doi:10.1017/S0033291710002497

Klonsky, E. D. & Muehlenkamp, J.J. (2007). Non-suicidal self-injury: A research review for the practitioner. Journal of Clinical Psychology/ In session, 63, 1045-1056. 

Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226-239.

Whitlock, J, Muehlenkamp, J., Purington, A., Eckenrode, J., Barreira, J., Abrams, G.B., Marchell, T., Kress, K., Girard, K., Chin, C., Knox, K. (2011). Non-Suicidal Self-Injury in a College Population: General Trends and Sex Differences. Journal of American College Health, 59, 691-698.

Memoirs of Interest
Kettlewell, C. (1999). Skin game: A Cutter’s Memoir. New York: St. Martin’s Press.

Audio resources
Episode 95 - Dr. Janis Whitlock: The Cutting Edge: Self-Injurious Behavior in Adolescents and Young Adults. (2012, April 30). Living Proof Podcast Series. [Audio Podcast] Retrieved from http://www.socialwork.buffalo.edu/podcast/episode.asp?ep=95

Gibson, T. (Host). (2011, October 13). Episode 5 – Cutting, Burning, NSSI and Our Kiddos. The Family Podcast Network. [Audio Podcast] http://thefamilypodcastnetwork.com/episode-5-cutting-burning-nssi-and-our-kiddos

Smith, B. (n.d.) The Practice of Nonsuicidal Self-injury in Adolescents—Part 1. ConsultantLive.com [Audio Podcast] Retrieved on August 13, 2012 from http://www.consultantlive.com/multimedia/content/article/10162/1858142

---

APA (6th ed) citation for this podcast:
Singer, J. B. (Host). (2012, August 10). Non-suicidal self-injury (NSSI): Interview with Jennifer Muehlenkamp, Ph.D. [Episode 73]. Social Work Podcast. Podcast retrieved Month Day, Year, from
http://www.socialworkpodcast.com/2012/08/non-suicidal-self-injury-nssi-interview.html