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Understanding Self Harm in Teens and Young Adults

March is Self-Harm Awareness Month. There have been reports of significant increases of self-harming behaviors in teens ages 12-17 and for young adults, as a general trend, over the past 10 years. About 17 percent of adolescents had engaged in NSSI at least once, according to an international meta-analysis of 52 studies, conducted by psychologist Jennifer Muehlenkamp, PhD, of the University of Wisconsin–Eau Claire and colleagues (Child and Adolescent Psychiatry and Mental Health). Other studies show that the highest prevalence is in this adolescent age population with rates decreasing for young adults and into adulthood.

A significant percentage of those who have attempted suicide also exhibit self-harm. Though if there is good news when discussing self-harm, it is that most instances of self-harm are non-suicidal, often referred to as Non-Suicidal Self Injury (NSSI). This is important to assess and understand because without imminent threat of death, it means we can be patient while treatment progresses and the person learns healthier ways of coping. It is understandable for caretakers to feel worried and fearful when working with or parenting a teen engaging in harmful acts. When we can understand the level of risk, it can help to manage reactivity when responding.

It can be difficult to understand why people might self-harm. While the particular triggers that can cause intense negative emotions are idiosyncratic, 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 those struggling.

Relationships can be both protective and reparative. Conversely, they can be conflictual, cause stress, and feel invalidating (however inadvertent). For many who turn to such harmful coping, relational ruptures (arguments with friends or parents, perceived rejection or breakups) seem to be common precipitants. 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, self-punish when feeling shame about a regrettable action or circumstance, 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 to 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 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 for 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 and available when discovering a teen has already harmed, though not so overly warm and 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. This means inviting teens to reach out for help under what will likely be painful circumstances, for them and perhaps us.

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 in efforts to 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 treatment 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 and 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 may trigger a deeply self-preserving counter control response. Express acceptance by validating the pain, any expressed emotions, stressors, or honest feedback they may offer, not the harmful behavior.

Change can happen when those hurting are supported by loved ones and working to learn and practice more adaptive and healthy coping behaviors. Learning ways to tolerate distress, practice more open expression of emotions and needs, and use their resources to problem solve the inevitable and sometimes unexpected hurts life presents, is the ultimate goal. Helping teens replace harmful with healthy coping can serve to reshape the earlier cycle (see diagram).

* 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. If you discover that your teen has self-harmed and they do not have a mental health care provider, seek an evaluation with a licensed mental health professional or consult your teen’s pediatrician as a starting point. This newsletter is not intended to assess, provide or replace any clinical advice or care.

1. Cornell University Self-Injury and Recovery Resources
2. To Write Love on Her Arms
3. The Trevor Project
4. McLean Hospital

~ Julie Baron, LCSW-C