March is Self-Harm Awareness Month. There have been reports of significant increases in self harming behaviors in teens ages 12-17 and for young adults, as a general trend, from 2006 to 2019. As has been reported widely (and in the 2021 advisory report from the US Surgeon General) the Pandemic has had additional impact on poorer mental health outcomes for youth and young adults.
If there is good news when discussing self harm, it is that most self harm behaviors are non-suicidal, often referred to as Non-Suicidal Self Injury (NSSI). This is important to assess and understand because without any imminent threat of death, it means we can be patient as the person learns healthier ways of coping (and thus can hopefully calm the reactivity of caring people around those who self-harm).
Many people have a difficult time understanding why people might self harm. While the particular triggers that can cause intense negative emotions vary person to person, there is a predictable cycle to self harm (see diagram).
You may also wonder what makes one person engage in self-harm and not others? Nature (temperament- sensitivity, reactivity, etc) and nurture (interaction with the environment- stressors, relationships, etc) play an interactive role. While we can’t change a person’s fundamental nature, we can help those individuals learn themselves and new ways of coping and make adjustments in the environment, including in our relationships with the person struggling.
Relationships can be both protective and reparative. Conversely they can be conflictual, cause stress, and feel invalidating (however inadvertent). Here are some considerations for using your relationship to effectively support a young person in your life you may be aware of or suspect is self-harming:
Respect that the NSSI has a function. It may be serving to quickly shut down highly painful emotional states or create sensation when a sense of emotional disconnect, dissociation or numbing occurs. We also need to respect that these behaviors in others are not ours to change or control. Rather we need to help the young person take ownership of their own safety and the goal to change behavior must ultimately come from them. Respect your teen as the expert of their own experiences.
Authenticity in the way we express concern and caring is important. It is ok to express that you are worried about the NSSI behavior and be honest about the negative impacts (there are both pros and cons to everything). If a helping adult is having a difficult time finding empathy and understanding that the pro of the behavior could be protective, it may be best, however, to refrain from saying anything that could be received as judgmental. As seen in the cycle of self-harm, the person is likely already shaming themselves, which only serves to keep the cycle going.
Kindness in the form of compassion for the person suffering will help them feel supported and validated as worthy of relationships and care even when they are harming themselves. Reminding those we love that our love form them cannot be shaken by their pain or painful behaviors, can help to reinforce a sense of worth and self-compassion. Note: we want to be supportive/available when discovering a teen has already harmed though not so overly warm/attentive that it inadvertently may reinforce self harm as a way of getting needs met. We want to let teens know we are there for them when they are hurting, encourage them to reach out, openly receive, and offer warmth, compassion and positive attention as much as possible, before self-harm occurs.
Predictability in the way we manage risk, create nonjudgmental spaces, and respond when we are told or discover someone has self-harmed will create a greater sense of stability. If we are treatment providers, we want young people to openly share when they self- harm so we can help them learn improved distress tolerance and understand the triggers so they can be predictive and learn to cope ahead. This means encouraging reporting or some form of tracking and regularly checking in when treating self harm is a goal. If we are parents, we want our teens/young adults to know we are there to support them (especially before they engage in any unsafe behavior). Even when we are angry or disappointed, or if they have made a mistake (unrelated to any NSSI) that warrants a consequence (reminder natural consequences that make sense tend to be the most effective) we want them to know we love them and want them to be safe (* see note below). If we are school personnel, we want to make sure we adhere to any risk management response procedures the school has outlined for safety concerns and that it is framed as a medical need/concern for wellbeing rather than anything disciplinary. Predictably reinforce your willingness to provide support before they engage in any NSSI and praise them when they do. The goal is to teach and reinforce appropriate help seeking behavior.
Acceptance is hard when those we love/care about are hurting themselves. Without acceptance of what is, there can be no change. Accept that when a young person engages in NSSI : 1) they are hurting, 2) judgement or asking why is not helpful, 3) they need help, and 4) the more others try to “control” the NSSI behavior, the harder it will be for them to own and change harmful behaviors (for some a sense of control can be a function of NSSI). In addition, adolescents are developmentally tasked with finding a sense of autonomy, so anything that feels taken out of their control triggers a deeply self preserving counter control response. Express acceptance by validating the pain or any expressed emotions, stressors, or honest feedback they may offer, not the harmful behavior.
* A note for parents: it is important not to punish self-harm behaviors. Work with your teens’ treatment professionals to develop an appropriate safety/response plan based on the needs of your teen. “Catching” your teen through deliberate searches or body checks can risk creating distrust in the relationship and further shame. For an effective support or response plan, consider the following: what is age appropriate, thoughtful vs. reactive, and collaborative with your teen and their care team. This newsletter is not intended to assess, provide or replace any clinical advice or care.
~ Julie Baron, LCSW-C