Key Takeaways
- Research indicates that approximately 40 to 60 percent of individuals who engage in non-suicidal self-injury also meet criteria for a substance use disorder, reflecting shared underlying mechanisms of emotional dysregulation.
- Both self-harm and substance use function as maladaptive emotion regulation strategies, providing temporary relief from intolerable emotional states through alteration of physical or psychological experience.
- Dialectical behavior therapy is the most well-supported treatment for co-occurring self-harm and substance abuse because it directly targets the emotional dysregulation that drives both behaviors.
- Treatment must address both behaviors simultaneously, as eliminating one without providing alternatives often leads to escalation of the other.
Understanding the Connection Between Self-Harm and Substance Abuse
Self-harm, clinically known as non-suicidal self-injury (NSSI), and substance abuse may appear to be very different behaviors, but they share a fundamental common purpose: both serve as strategies for managing emotional pain that feels otherwise unmanageable. This shared function explains why the two behaviors so frequently co-occur and why treating them in isolation rarely produces lasting change.
Non-suicidal self-injury includes behaviors such as cutting, burning, hitting, scratching, or other deliberate self-inflicted harm performed without intent to die. Like substance use, these behaviors activate the body's endorphin system, producing a temporary sense of relief, control, or emotional numbness. The neurochemical mechanisms are strikingly similar: both self-harm and substance use provide rapid alteration of an intolerable internal state.
At Trust SoCal in Orange County, our clinicians understand that self-harm and substance abuse are not problems to be punished or shamed but symptoms of profound emotional suffering that require compassionate, skilled intervention. Our dual diagnosis program addresses both behaviors within an integrated framework that targets the underlying emotional dysregulation driving them.
If you or someone you know is engaging in self-harm, please reach out for help. Contact the 988 Suicide and Crisis Lifeline by calling or texting 988, or reach Trust SoCal at (949) 280-8360.
Shared Mechanisms: Why These Behaviors Co-Occur
The high co-occurrence rate of self-harm and substance abuse is not coincidental but reflects shared neurobiological and psychological mechanisms that predispose individuals to both behaviors.
Emotional Dysregulation
Both self-harm and substance use are driven by difficulties in managing emotional intensity. Individuals who experience emotions at extreme levels, who have limited tolerance for emotional distress, or who lack effective strategies for processing difficult feelings are vulnerable to any behavior that promises rapid emotional relief. Self-harm and substance use simply represent different tools in the same dysfunctional toolbox.
The emotional dysregulation underlying both behaviors often has developmental origins. Childhood environments that were invalidating, abusive, or neglectful failed to teach the child how to identify, tolerate, and process emotions effectively. Without these foundational skills, the individual reaches adulthood with intense emotional needs and inadequate resources for meeting them.
Neurochemical Overlap
Self-harm triggers the release of endogenous opioids, the body's natural painkillers, producing a sense of calm and relief that mirrors the effects of opioid drugs. This neurochemical response explains both the immediate relief that self-harm provides and the difficulty of stopping the behavior once it is established. The brain learns that tissue damage produces chemical reward, creating a cycle that parallels substance dependence.
Additionally, both behaviors affect dopamine and serotonin systems involved in mood regulation and reward processing. The temporary neurochemical normalization provided by either self-harm or substance use reinforces continued engagement with these behaviors despite their harmful consequences.
Treatment Challenges and Considerations
Treating co-occurring self-harm and substance abuse presents unique clinical challenges that require specialized expertise. One of the most important considerations is the risk of symptom substitution: when one behavior is eliminated without addressing the underlying emotional dysregulation, the other behavior often escalates to compensate. An individual who stops drinking may increase self-harm frequency, or vice versa, because the unaddressed emotional needs simply find a new outlet.
This dynamic underscores the importance of integrated treatment that simultaneously addresses both behaviors while building the emotional regulation skills that make them unnecessary. Treatment providers at Trust SoCal are trained to manage both conditions within a unified treatment plan rather than referring self-harm and substance abuse to separate specialists.
Safety planning for individuals with co-occurring self-harm and substance abuse must account for the interaction between these behaviors. Intoxication reduces inhibitions and pain sensitivity, which may increase the severity of self-harm episodes. Harm reduction strategies must address both substances and self-harm implements, with safety plans updated regularly as treatment progresses.
DBT: The Gold Standard Treatment
Dialectical behavior therapy was specifically developed for individuals who struggle with emotional dysregulation, self-harm, and suicidal behavior, making it ideally suited for the co-occurring presentation of self-harm and substance abuse. DBT has been adapted for substance use disorders and has strong research support for reducing both self-harm and substance use simultaneously.
The four skill modules of DBT directly address the deficits that drive both behaviors. Mindfulness builds awareness of emotional states before they reach crisis intensity. Distress tolerance provides tools for surviving intense emotional pain without resorting to self-harm or substance use. Emotional regulation teaches strategies for reducing emotional vulnerability and managing difficult feelings. Interpersonal effectiveness builds the relationship skills needed to seek support and communicate needs.
- 1Individual therapy: weekly sessions addressing target behaviors in order of severity, with life-threatening behaviors prioritized first
- 2Skills group: weekly group sessions teaching and practicing DBT skills in a structured, educational format
- 3Phone coaching: between-session access to the therapist for real-time skill application during moments of crisis
- 4Diary cards: daily monitoring of emotions, urges, and skill use that provides data for therapy sessions and tracks progress over time
Building a Life Worth Living
A core concept in DBT that resonates deeply with individuals recovering from self-harm and substance abuse is the goal of building a life worth living. This concept acknowledges that reducing harmful behaviors is necessary but insufficient; the individual must also develop positive experiences, meaningful relationships, and purposeful activities that make life genuinely worth engaging with.
Trust SoCal in Orange County supports this positive vision of recovery by helping clients identify their values, explore interests, develop talents, and build connections that provide genuine meaning and satisfaction. When life becomes rich and engaging on its own terms, the motivation for self-harm and substance use naturally diminishes.
Recovery from co-occurring self-harm and substance abuse is possible. With specialized treatment, compassionate support, and consistent skill practice, individuals can develop healthy ways of managing their emotional lives. Call Trust SoCal at (949) 280-8360 to learn about our dual diagnosis treatment options.
Rachel Handa, Clinical Director
Clinical Director & Therapist
