New PMHNPs: Don’t Forget to Ask About Non-Suicidal Self-Injury During Your Safety Assessment

Jul 30

Written By Anna .

When completing a psychiatric safety assessment, asking about suicidal ideation is an essential part of the evaluation. But there’s another important question that can sometimes get overlooked:

Is the patient engaging in, or thinking about engaging in, non-suicidal self-injury (NSSI)?

NSSI can include behaviors such as cutting, burning, scratching, hitting oneself, or other intentional acts of self-injury without the intent to die.

For new PMHNPs, it can be easy to focus heavily on suicidal thoughts, plans, intent, and access to means during a safety assessment. Those questions are critical—but they don't necessarily tell you whether a patient is experiencing urges to self-injure.

Why You Should Ask About NSSI Directly

One thing I've learned in practice is that patients don't always spontaneously disclose self-injury.

I've had multiple situations where a patient had no previously documented history of NSSI, but when I specifically asked about it, they disclosed that they had either recently engaged in self-injury or had been thinking about doing so.

If I hadn't asked, I may not have known.

And that information matters.

Learning that a patient is engaging in or considering NSSI can provide important information about their current level of distress, coping strategies, emotional regulation, and overall safety. It can also influence the treatment plan.

A Negative Suicide Assessment Doesn't Rule Out NSSI

One of the most important things for new Psych NPs to remember is that NSSI and suicidal behavior are not interchangeable.

A patient may deny suicidal ideation while still engaging in self-injury.

That means asking:

"Are you having thoughts of suicide?" of “Have you had thoughts of not being alive?”

doesn't necessarily answer the separate question:

"Have you had any urges to hurt yourself or intentionally injure yourself?"

Both questions can be important.

The presence of NSSI is clinically relevant information that should be considered in the overall safety assessment.

How to Ask About NSSI

If you aren't routinely asking about NSSI yet, you don't necessarily need to make the question complicated.

You can ask directly:

"Have you had any thoughts about intentionally hurting yourself, such as cutting or burning yourself?"

You can also ask about recent behavior:

"Have you intentionally hurt yourself in any way recently?"

If the patient says yes, you can follow up to better understand what happened, including the type and frequency of the behavior, when it last occurred, what was happening before it occurred, what the patient was hoping to accomplish or experience, and whether there was any suicidal intent.

The goal isn't simply to check a box. It's to understand what the behavior means for that particular patient.

Don't Assume They'll Tell You

If there's one thing I would want every new PMHNP to take away from this, it's this:

Don't assume that patients will spontaneously tell you about NSSI. Ask.

A patient can have no documented history of self-injury and still be experiencing it.

A patient can deny suicidal ideation and still be struggling with self-injury.

And a patient may never think to mention it unless you specifically create an opportunity for them to do so.

Asking doesn't mean that you're assuming the patient is engaging in NSSI. You're simply making sure that you've assessed an important part of their safety and mental health.