When someone is experiencing urges to self-harm, it can be really difficult to think clearly. Psychological pain can cause executive function (that is, the set of complex brain processes that help us with goal-directed decision-making) to go offline. It can be helpful to have a plan in place for when these times come.
That’s why I created this flowchart (aka a decision tree). This resource is not meant to be an endpoint or a one-size-fits-all; it’s a starting point. An example. An on-ramp to:
- Conversations about what to do, who to call, and where to go if we feel urges to self-harm;
- Developing our own personalized plans so we can get better care from self and others;
- Turning a crisis plan into an action plan that can help us know when to reach out for help.
Some people may find this flow chart to be a helpful resource as published; however, I recommend using it as a conversation starter or creative prompt for making your own flowchart decision tree that’s customized individually. In this way, you can make a decision tree filled with things you know work for you, while skipping the things that don’t.
Download These “Handling Self-Harm” Flowcharts
This PDF download includes two sets of images, in color and in black-and-white:
- Handling self-harm urges flowchart, ending with instructions to contact crisis resources.
- Handling self-harm urges flowchart, ending with harm reduction principles.
This educational resource is not advice, counsel, or treatment. For more information, carefully review the terms of service you will be required to agree to during checkout. Harm reduction may not be appropriate for every person. Consult with a licensed mental health provider.
Why You Should Make Your Own Self-Harm Flowchart
Like a crisis plan, everyone’s decision tree for coping with self-harm urges may differ. While my flowchart incorporates ideas from DBT, including distraction and urge surfing, they’re just general principles. The advantage of making your own flowchart for coping with self-harm urges is that you can be specific.
For example, you know which person in your crisis plan contacts can support you and offer the best support while managing their own reaction to what researchers term “non-suicidal self-injury” urges.
You also know the specific positive and negative distractions that have worked for you in the past. Like a crisis plan, a flowchart can be a living document – one that gets updated as you learn more about yourself, your triggers, and ways that helped you cope in the past.
For many of us, depending upon where we are in recovery from self-harm, we may find that the order of this flowchart just doesn’t work for us. For people who know themselves well (or have a sense of what might work a little better), making your own self-harm decision tree flowchart is helpful because you can create a guide that keeps the order of these steps in mind. For example, reaching out to a partner or a professional might be more helpful for you before trying alternatives.
How to Create Your Own Decision Tree Flowchart for Coping with Unwanted Urges
- Begin in the top center or top left-hand corner of a blank page. Draw a box. Inside the box, place the words “I feel _____ and want to _____.” Replace your feeling and urge with the blanks shown here.
- Next, think of two ways to deal with this urge. Frame it with the question. (Yes/no questions work best.) Write down the question and circle it, then place a line between the question and the previous bubble describing feelings and urges.
- Now, draw a “yes” line and a “no” line from the question box you just drew. At the end of each line, write the yes or no option.
- Choices have consequences. For the next layer of your decision tree flowchart, you will write the next step which you anticipate will follow the previous answer to the question. Your responses are probably diverging at this point, but you can rejoin them by drawing lines that reconnect.
As you begin to create your own flowchart that illustrates the choices and decisions you navigate when you’re coping with the self-harm urge, keep your recovery in mind. While one could decision-tree themselves to a very dark place, that in itself would be a form of self-harm. Instead, be mindful of your recovery goals and use the items in your crisis plan (the people, activities, places, and things that help you stay safe). Structure your flowchart so that each tier of decisions helps you encounter a different way of accessing the care you need to thrive.
A flowchart helps us, our loved ones, or our clients think imaginatively when we are doing well, and to have custom-made, compassionate instructions for dealing with darker days. Making our own flowchart of what works, what doesn’t, and what we should do if urges get stronger can help us be more proactive and more successful in meeting our recovery goals.
Why this Download Includes a Harm Reduction Version
This decision tree flowchart includes two versions:
- One ending in a crisis call,
- and the other ending in a version of harm reduction.
When it comes to other addictive behaviors, harm reduction is a fairly standard practice. However, with self-harm, there’s often an all-or-nothing response. Interestingly, this is especially true in the USA. The UK has adopted harm reduction as standardized recommended practice for working professionally with those who self-injure 1. It’s important to remember that if self-harm is someone’s only effective coping mechanism, that probably won’t shift overnight, even with treatment.
A growing body of research* suggests that it is worth considering if we should focus less on an all-or-nothing approach, and more on developing new coping skills (like using social supports or participating in activities that self-soothe), providing tools and resources to learn to tolerate painful emotions (like information and support in learning to “urge surf” and mindfully noticing and “ride” the wave of the urge to harm) and providing information on harm reduction (like how to minimize the harm of self-harm episodes if they do occur, through hygiene, good wound care, and making sure that shame doesn’t result in neglect of open wounds).
You can choose which version is right for you and the person(s) you want to share this art with. Download both versions in the single PDF file below. Click here to jump to the download.
To learn more about urge surfing, and how ride out urges without acting on them, check out this article
*For academic research supporting harm reduction for self harm, see https://doi.org/10.1111/jpm.12508 or https://www.sciencedirect.com/science/article/pii/S0272735806000961 or this 2020 study: https://www.tandfonline.com/doi/abs/10.1080/13811118.2020.1823916 or any of these resources:
“The 2004 guidelines published by the (UK) National Institute for Health and Clinical Excellence (NICE) recommend the use of harm-reduction for people who hurt themselves (self-injure) in primary and secondary health care settings”: Inckle, Kay. “The first cut is the deepest: A harm-reduction approach to self-injury.” Social Work in Mental Health 9.5 (2011): 364-378.
“Nonsuicidal self-injury (NSSI) is a prevalent phenomenon, yet no sufficiently effective treatment approach exists, leading researchers to consider how a reconceptualization of NSSI phenomenology may be necessary to optimize treatment. Multiple novel reconceptualizations seem to converge on the idea that NSSI provides certain benefits (e.g., affect regulation) that lead to nonlinear recovery processes in which cessation is not always possible.” – Preston, E. G., & West, A. E. (2021). Straight to the Source: e-Communities for Nonsuicidal Self-Injury and the Emerging Case for Harm Reduction in the Treatment of Nonsuicidal Self-Injury. Clinical Psychological Science, 21677026211049367.
“…allowing harm is not necessarily contrary to the professional’s duty of care, and in fact it may be required if the benefits are significant and likely to outweigh such harm. Harm minimization provides a means of working with an individual in a way that recognizes their autonomy and accepts that they have a different way of coping with distress.” Sullivan, P. J. (2017). Should healthcare professionals sometimes allow harm? The case of self-injury. Journal of Medical Ethics, 43(5), 319-323.
If you or someone you care about is in danger, call 911 or, in non-emergency situations, text the Crisis Text Line at 741741.
Image Description for Screen Readers:
The first image depicts a hand-drawn flowchart on a green background. The flowchart begins with a gold frame, which has a white inner layer that reads “Uh oh… I want to self-harm.” The first question in response to this is written on a yellow flag and reads “Do you have a crisis plan?“
If you answer “A what, now?” to “Do you have a crisis plan?” then the next step is to make a crisis plan.
If you answer “Yeah, but it’s unhelpful” to “Do you have a crisis plan?” then the next step is to make a crisis plan.
If “yes,” to “Do you have a crisis plan?” then the next question, written on a white computer screen, reads “Have you tried 3 positive alternatives?” If “yup,” the next question, written in a white box, is “Have you tried 3 negative alternatives?” If no, then list three alternatives you can do right now. If “yes,” then the question asks, “Still want to self harm?” If “yup,” then the next question, written in a white box reads, “OK. Is there someone who might help to talk to you?” If “yes,” then a gray megaphone reads, “reach out.”
If you answer “yes” to the question “Do you have a crisis plan?” but answer “no” to “Have you tried 3 positive alternatives,” then the next question, written in an oval-shaped gold frame asks, “List 3 activities (big or small) you can do right now.” After listing the three activities, you don’t want to self-harm anymore, then “Yay!” However, if you do want to still self-harm, then it flows into the question of “Is there someone who might help to talk to?” If yes, “Reach out!” If “not really,” then “Have a talk with a journal or stuffed animal about what is behind the urge.” If you’re not feeling “self-harmy” then “Yipee!”
If you’re still feeling “self-harmy” afterward, then “Can you wait one hour?”
If you think you can wait an hour or you know that you can, then try to play, work, sleep, or learn a new skill. Repeat this loop until the urge subsides, if possible.
If “no,” then it’s time to reach out to crisis resources for care. Below this is a list of “In case of emergency, call…” to be filled in for use.
Note: a “negative alternative” includes things like snapping a rubberband on your wrist or holding a cold ice cube.
Image was created by Lindsay Braman.
- Inckle, Kay. “The first cut is the deepest: A harm-reduction approach to self-injury.” Social Work in Mental Health 9.5 (2011): 364-378.