What is Self-harm?
Currently, the field of psychology uses the term “Non-Suicidal Self Injury (NSSI)” to describe self-harm. Self-harm can be a number of things, including but not limited to scratching, cutting, burning, hitting oneself: with the specific quality of doing harm to oneself on purpose. Self-harm is not nearly as uncommon as one may think, particularly with teenagers and young adults. As the research in the area of NSSI has grown, practitioners have come to conceptualize self-harm as a way of coping, thus indicating a potential dearth of more adaptive coping skills, or perhaps a more significant level of distress that renders a teen’s usual coping skills insufficient or ineffective.
Why Do People Engage in Self-harm?
It could be for a number of reasons. A quick overview of the literature would suggest that people who engage in self-harm do so as a way to control overwhelming emotions and help themselves calm down. It may help a teenager to escape from feelings and almost “numb-out”, almost giving them a reprieve from the intensity of the emotions that they are experiencing at that moment. Another function of self-harm could be a way for teens or young adults to punish themselves, or as a way of indirectly punishing others.
How to React and What to Do?
In the moment, you may find yourself wanting to yell or scream, or cry however this can make things more difficult or can even make it difficult to get your teen to want to talk about their self -harm with anyone. If you can, generally the best reaction is to try to be calm and work to validate and empathize with your child (To read more, visit the Do’s and Don’ts Section of this article). After you have checked in with your child, your next step should be to connect your child, adolescent, or young adult to a therapist as soon as possible. While self-harm is not usually an attempt on one’s life, you need to make sure someone qualified (ie. a trained clinician) is able to assess whether or not this was or is a factor in your child’s self-harm. Even if trying to end their life was not part of the goal or their thought process, it is still incredibly important to get your child connected to a counselor. This is for a couple of reasons:
- While it may be the first time you as the parent discovered your child’s self-harm activity, it is NOT likely the first time they have self-harmed: In my practice, I often have teens and young adults that are brought to therapy by their concerned parents because the parents have just discovered a laceration on their child’s wrist, arm, or leg. More often than not, once my teen clients are in a session one-on-one, they often endorse engaging in self harm for quite some time before they were “caught.”
- While self-harm may not be an attempt on one’s life, the research indicates that the longer self-harm occurs, the more likely severe injury or death can occur. Research suggests self-harm behaviors, like cutting, tend to increase in intensity as the self-harm continues. What may have started as a few scratches here and there, may increase to the use of more dangerous cutting tools, as well as deeper or more frequent cuts. This may occur for a few reasons, one of which may be that the person develops almost a “tolerance” for the pain caused by self-harm, thus leading to less of what it is the teen “gets out of it” (whether it is a sense of relief, a sense of numbness, an experience of feeling, etc). Therefore, this “tolerance” often leads to more intense measures being taken to get the same “effect,” which can lead to infection, as well as an increased risk of accidentally nicking a vein or artery, which could lead to severe consequences.
- Self-harm “works.” What I mean by that is this: Self-harm can often be conceptualized as a coping skill – a maladaptive coping skill, but a coping skill nonetheless. And to be perfectly candid, there are not many other therapy skills that can give clients the immediate relief or experience that self-harm does. So if you are expecting your child to just stop, it is highly likely they are going to find it very difficult without additional support. In fact, some teenagers at times indicate that they do not want to stop because their method of self-harm is so “effective”; others may want to stop, but are at a loss as to what else could help them in those intense moments.
- Engaging in self-harm does not automatically mean your child has a mental illness, however, it would be beneficial to have a professional assess whether your child’s self-harm is a function of a lack of coping skills or a symptom of an underlying mental health issue, such as depression or anxiety.
Common Myths and Misunderstandings Around Self-Harm
- It’s just a cry for help, a way for my child to get attention: This is the most common myth when it comes to self-harm. For one, if you recall my previous statement, most people have been engaging in self-harm for quite some time before they are “discovered” and brought to therapy. If the only goal of self-harm was attention, it would be way more likely that the teen would make it known! Teens generally desire more privacy and separation from parents, which is fairly age-appropriate. Self-harm as a function of seeking attention is in direct conflict with this developmental desire that emerges around this age. At the very least, for the very few who engage in self-harm for attention (less than 4% according to Dr. Hollander, author of Helping Teens Who Cut), I often will prompt parents to consider the way in which their teen or college-age child is trying to get attention: they are actively causing physical pain to themselves, (sometimes to the intensity of cutting into their body) which goes against our inherent, basic biological drive towards survival. This likely indicates the extremity of the child’s emotions or experience, that they overwhelm or override their own biology.
- It is because their friends are doing it: A lot of parents come to me a bit baffled, stating that no one was cutting back in their time and it seems to have become a “fad” or rather popularized thing among teens. This could be for a couple of reasons:
- It could be because teens are more open about it than they ever have been. They tend to be more open about a number of things: gender identity, sexual orientation, etc. I find that most teens and young adults have a very different view of mental health and therapy compared to their parents (or their parents’ generational view). Generally speaking, most of the teens I work with seem to view mental health as far less stigmatizing and find it helpful to talk about with others.
- Another reason you may be hearing about self-harm a lot more these days is that research has finally caught up with what is happening in society. That is, people may not have heard about NSSI before because in the past most practitioners and parents would have labeled the self-harm as a suicide attempt. Thus prompting a very different intervention and protocol. As I mention in my third myth, this is no longer how we conceptualize self-harm.
- Some parents worry that their child has been pressured by their friends into self-harming: that by being around other kids who self-harm, their own child self-harms. Research indicates it is likely the other way around: that a child who starts to self-harm will likely seek out peers who are engaging in similar behaviors, almost as a source of support. These are friends who really “get it.”
- It is an attempt on their life: Twenty years ago, this likely would have been the number one myth or assumption surrounding self-harm. Thankfully, both the research and therapists working with people who self-harm have worked to increase our understanding around what self-harm is and what it “does” for our clients. That being said (as I stated previously), while self-harm is usually not a suicide attempt, it is still important that you have a therapist assess for safety both around self-harm and suicidal ideation with your teen, before assuming there is nothing else going on.
How Do You Involve Yourself as a Parent?
While it may be very difficult for you, it is important to be able to talk to your child about how they are feeling and their self-harm, without overdoing it (*remember your teen is likely seeking some parental separation and moving more towards finding support in peers). Often, parents find themselves struggling to talk about it, either because they worry that in talking about the self-harm it will make their child engage in it more, or because they don’t know what to say.
Many parents sit in my office and share that they feel like they are “walking on eggshells,” afraid to do anything that might make their child react negatively, explode in anger or tears, and self-harm.
Here is a quick list of some Dos and Don’ts that might help you navigate how to involve yourself. You may notice that a lot of the tips are focused on your own reaction(s) and how to communicate effectively:
Don’t: Ignore it.
A lot of the parents I work with initially feel like they do not want to bring up the conversation of self-harm. Some feel like it may be like poking a sleeping bear. Why would you even risk it? Other parents worry that it might bring more attention to it. The problem with ignoring it is that it still tends to “linger” in the air. It infiltrates what and how you think about your teen. Instead of thinking “oh my kid is taking a shower because they just got home from a soccer game,” you may find yourself thinking “they are in the bathroom to self-harm” which then likely impacts how you interact with your teen. It also can impact how your teen thinks about you. If your child knows that you are aware of their self-harm and yet there is never a discussion around it, this can leave the door open to a whole host of negative interpretations from your teen, such as “my parents don’t care about me,” or “if they don’t talk about it, it means they don’t think it is a big deal.”
Don’t: Talk about it all the time.
Many of my teens struggle in talking with their parents because they feel like either because they fear how their parents might react (ie. with high emotion, with punishment, or with sarcasm) OR because it is the ONLY thing their parents talk about. Most people who self-harm experience a great deal of shame or guilt around their NSSI, so having long, drawn-out conversations almost keeps them locked in that state even longer. Another way to think of it is that if your child experiences shame around the self-harm, talking about it all the time might actually reinforce the idea that your teen SHOULD feel terrible about it. Having a dialogue to “touch base” can help have a check-in without having self-harm become the overwhelming theme of every conversation.
Do: Work with your child and their therapist to develop a language around self-harm.
Having an agreed-upon language around self-harm can serve a number of positive purposes:
- It can help to destigmatize self-harm and bring the conversation out into the open.
- It can help to decrease misunderstandings, either from the teen’s perspective or your own.
- It lets your teen know that you are invested and willing to learn and help.
- It gives you a way to check-in around the self-harm without making a big “to-do” about it.
- In addition, having the teen be part of the conversation can increase their own buy-in, willingness to talk to you, and potentially reduce the chances that the language can cause a negative reaction from your teen. To put it plainly: if they are a part of creating a safe self-harm language, it will make it really hard for them to complain about or react to it.
Don’t: Freak out.
While it is natural to have a reaction to your child’s self-harm, it is important to be aware of your own emotional reaction in the moment. Screaming, yelling, crying, or removing all friends and privileges may actually make things more difficult, both for you and for your teenager.
Do: Find a way to talk about your child’s self-harm that reduces stigmatization.
This can be done by taking an open, non-judgemental stance to what is happening. It sometimes helps to change the way you think about your child’s self-harm. Many parents report finding it helpful to think about it as a coping skill, thus alerting them to the fact that their child is struggling to cope with something and does not have the skills to cope effectively.
Don’t: Get upset or chastise your child if they come to you telling you that they have an urge to self-harm.
Again, while it is hard to hear, the fact that your child is coming to you before they have done anything is a great thing! It means that they are becoming more aware of their self-harm urges, and have enough control to seek you out for help!
Do: Give positive reinforcement and support.
It can be hard to seek out others in a time of need, so sharing that you are proud that they are aware and thankful that they came to talk to you is a great thing. Of course, you want to make sure that you do so in a language that works for you and your teen (ie. if you don’t usually talk in long-flowering sentences, saying “I’m so proud of you; you really are doing a fantastic job of it! And I am just so grateful for you letting me into your process!”, it might feel disingenuous to both yourself and your teen). This is where having developed a common language can really help!
Don’t: Tell them you understand, that you’ve been there, that others have it worse, or immediately jump into problem-solving.
All of these approaches, in their own way, may actually serve to make your teen feel invalidated. While problem-solving is not inherently bad, many of my teens feel like they can’t talk to their parents because they immediately try to problem-solve. Sometimes all your teen may need is a listening ear, which can later move to problem-solving.
Do: Learn how to validate.
A lot of people feel as though they know how to do this, but often it doesn’t quite hit the mark. There are a few tips that can help you be more effective in this area. Pay attention: while this may seem like a no-brainer, we spend so much time on our phones, checking emails, or thinking about what needs to happen to dinner, that you may not actually hear what your teen says. Another way is to acknowledge the person is feeling, and reflect back what you heard your teen say, without being judgmental.
Most research around self-harm links it to issues around being emotionally-overwhelmed or impulse control issues, and recommends a specific therapy interaction to follow suit. However, new research and treatment approaches indicate that there are two overarching coping styles and biotemperments that people experience, and that the best treatment for your teen actually depends on which pre-existing underlying personality traits your teen has. Why is this so important? Well, as much as it would be nice to be able to tell you that there is a “one-size fits all” therapy approach, it does not exist. It is important for the therapist to understand the function of the self-harm for their client, as various functions of self-harm may actually need a different therapeutic approach to be effective. Let me walk you through each of the coping types and corresponding evidence-based treatments:
The emotionally Under-Controlled (UC) type: This type follows more closely with the traditional model of conceptualized self-harm behavior. These are teens or young adults that even from a young age (around 4 or 5) could be described as impulsive, engaging in perhaps erratic behavior, and are very much driven by the mood or emotion of the moment. These are people who may seem like everything is terrible one moment, and the next minute things are completely fine. They may be described by others as temperamental or very “hold-and-cold.” This likely indicates that their self-harm comes from a place of trying to cope, feeling overwhelmed, and is likely an impulse of the moment.
The UC Self Harm Treatment Approach: The treatment approach that tends to be the most effective for this individual is Dialectical Behavioral Therapy (DBT). DBT is an evidence-based therapy approach originally developed for adults with Borderline Personality Disorder. Over time, DBT has been found to be effective in working with a variety of populations, including emotionally dysregulated teens and young adults who are engaging in NSSI.
DBT works to help people who struggle with intense emotions that are easily triggered and difficult to control. It works by helping these clients learn concrete skills to help regulate and get back in control of their emotions. DBT also works to specifically target self-harm with a module that focuses primarily on distress tolerance skills. These are skills that are meant to help clients “ride the wave” of their self-harm urge (or impulse) by doing anything else in the moment that helps them get through the urge without giving in to it. Essentially, it is developing skills to be able to get through the moment without making the situation worse. DBT also works on increasing mindfulness as well as the client’s ability to more effectively regulate emotions in the moment so that emotions are less likely to escalate, which could decrease self-harm urges from even occurring. (You can find more information on DBT here and here).
The emotionally Over-Controlled (OC) type: This type characterizes people who can be described as shy, more reserved, can delay gratification, are detailed-focused, and “mask” their inner-feelings. These people could be viewed as striving for perfectionism, taking life very seriously, and avoid mistakes at all costs. A misnomer may be assuming that this person never has emotional bursts. People who are OC can have emotional outbursts (called emotional leakage), but it tends to occur in a more private setting with “trusted, familiar” people, rather than having an outburst in the parking lot at the grocery store or at work. The general theory is that people who are OC and engage in self-harm do so less from the mood or impulse of the moment, but from a place of planned, rule-governed behavior. Self-harm for these individuals is more likely to serve as a function of punishment, either towards themselves or to others. The self-harm is also more likely to be delayed, or planned or thought about throughout the day. Even the actual self-harm can be different, as it may occur in a more private location (like along the ribs or on legs) or it may be a more rigid, measured harm (like 5 cuts in a row, and are fairly meticulous).
The OC Self Harm Treatment Approach: There is a groundbreaking evidenced-based approach that effectively tackles the issues OC people face called Radically Open Dialectical Behavioral Therapy (RO DBT). While the treatment manual came out about a year ago, there is over a decade of research indicating the success of this approach for OC individuals.
RO DBT also has a skill that works on urge-surfing, but from a different perspective, less from a place of distraction, more so from a place of reducing physiological arousal and being able to separate from the urge of physical response and move on. RO focuses on things in a different way. One of the aspects of people who are overcontrolled is that they may not want to engage in any traditional DBT distress tolerance skills because they do not feel like they deserve to feel better (ie. they deserve to be punished and therefore are significantly less likely to use skills to reduce self-harm). Therefore, RO tackles other aspects to the person’s thinking and examines how they engage with others and themselves to change the way the client views the world. (You can find more information on RO DBT here and here)
Key Factors that Differentiate UC from OC:
|The UC Individual||The OC Individual|
|High Threat Sensitivity*||High Threat Sensitivity*|
|High Reward Sensitivity||Low Reward Sensitivity|
|Open express emotions||Low emotional expression/awareness|
|Mood-Driven Behavior||Rule-Driven Behavior|
|Self-Harm as Coping||Self-Harm as Punishment|
*These characteristics are the same. However, they are important to note as these individuals are biologically predisposed to being more aware of and sensitive to threat. Threat does not necessarily mean an active threatening person in your face. Threats can be something as neutral as seeing someone taking a deep breath or sigh. Individuals who are sensitive to threats are significantly more likely to view stimuli, like a sigh, as something negative (i.e. the person being displeased, rude, or ignoring the individual).
Resources and Other Professionals in the Tampa Bay Area:
Online Resources: A good place to start can be online. The directory I tend to make the most use out of and find the easiest to use is: www. psychologytoday.com This website is essentially a directory of therapists, whether they are LSCWs, Master’s level clinicians, PhDs, PsyDs, or Psychiatrists. A heads up, this directory is not extensive, but it can be a good start to finding what is near you, who around you does or does not take insurance, therapy rates, and the therapists’ experience. When looking online, if you have a teen or young adult that you are looking to get connected, I encourage you to look for someone that specializes in that age group. I find that teens often need a different (more flexible, creative perhaps?) approach to get them engaged and connected. The research shows that one of the most important predictors of positive therapeutic outcomes is the therapeutic alliance; the relationship your teen has with the therapist. I would also encourage you to look for therapists that specialize in therapies like Cognitive Behavioral Therapy (CBT), DBT, or RO DBT.
There are a few resources in the Saint Pete and Tampa Bay area:
Integrated Care Clinic (ICC) in Downtown, St Pete. Yup, that’s me, and the clinic I work in! ICC has both DBT and RO DBT-trained clinicians. We provide individual DBT-informed and RO DBT-informed therapy. We currently do not have a DBT group running. However, we do have a weekly RO DBT skill class! We also have therapists that have specialized training in working with the adolescent and college student population.
Tampa Bay DBT in Tampa: This is a group practice that provides adherent DBT treatment (ie. weekly individual therapy, weekly group therapy, and phone consultation) and RO DBT treatment as well. They also run DBT groups and RO DBT classes. For more information on the difference between adherent DBT and DBT-informed treatment, here is a blog that tackles it.