Self-Harming Behaviors and Teenagers

Reflected Sadness
By: Victor Bezukov

Self-harming behaviors have garnered a great deal of attention over the past few years. While the prevalence of intentional self-harm – the most common of which include cutting and burning – continue to rise, it is difficult to truly understand the rationale for these behaviors. Nonetheless, it has become somewhat of an “en vogue” coping strategy many teenagers are using to deal with depression and heightened emotionality.

Cutting has reached the mainstream media. Titles such as Willow and Cut tell stories where the main protagonist is battling tragedy and loss through the use of cutting. Social media is full of self-reports and photos of teens communicating with one another about their use of self-harm to cope and mask strong negative feelings. But why do they use cutting to manage their depression? And more importantly, what do we do about it?

Why Cut?

While both questions are equally challenging to answer, the first presents as especially challenging. Parents often learn about their teen’s self-harming behaviors after it has been occurring for some time. And even then, it is often by accident (or by fortune). So when we ask about the purpose of the self-harm, it is hard to know if we are getting a complete and honest report.

The first thing that should be mentioned is that hard data about self-injurious behavior is difficult to come by. Of course, the only statistics we have are based upon those who either self-report self-harming behaviors or those who’s actions have been discovered by parents or professionals. As such, it is highly probable that many more teens and young adults use cutting as a coping mechanism.

That said, in 2008 a study was published estimating that somewhere between 1/3 and 1/2 of all teens in the United States have engaged in some type of self injury. This statistic, admittedly, includes more than just cutting or burning (it also includes eating disorders, such as anorexia). Nonetheless, this is a significant number of youth who are engaging in volitional attempts to inflict harm on themselves.

This is not just a problem in the United States, other countries are seeing a similar rise in the prevalence. The United Kingdom, for example, has published recent statistics suggesting that about 13 percent of 15- and 16-year-olds purposefully injure themselves. As such, it is clear that this has become an international concern and dispels the myth that cutting is a problem with US teens “seeking attention.”

Knowing that intentional self-injury is not a cultural phenomenon, it is important to look at the other reasons why teens injure themselves. Most often, self-harming behaviors are maladaptive ways to manage emotional distress, intense feelings that they cannot otherwise resolve. They may feel intense pressure on them – even though their parents may not perceive placing any pressure on them at all. I often hear from distressed teens who complain about the pressure from their parents, yet the parents do not perceive their “expectations” as true “pressure.” Even if they are not intended to be pressures, they are taken that way by the teen.

Some teenagers hurt themselves because of social conflicts and bullying. We have recently heard many reports in the media about teenagers and young adults hurting themselves – even to the point of suicide – due to bullying and social ridicule. In fact, this issue has become so severe that many states now have laws prohibiting bullying.

The bottom line is that nearly all self-harm is an expression of intense sadness, anger, or frustration that the individual cannot cope with. These are feelings that – for one reason or another – cannot be resolved with any other skill or technique that the teenager feels he/she has available. Certainly it does not help that this maladaptive strategy spreads through word-of-mouth. One teen who self-injures tells another teen about it, and before you know it, we have a situation where many teens – even those who have other strategies at their disposal – are using self-harm to cope with the unwelcome feelings.

“Self-Harm Does Not Make Sense!”

To many, the use of self-harm does not make any sense. How does hurting yourself help you cope with depression or anger?

The short answer is that it helps because… it helps. What I mean is that when I talk to teens who have injured themselves, they offer a variety of reasons why it helps. Some say that it helps them feel again (referring to the numbness that often accompanies depression). Others say that the pain makes them “feel alive.” Still others say that the physical pain is a distraction from the emotional pain. So whether there is a real “benefit” or not, it helps because it meets some need.

Theoretically, there may be some neurochemistry behind the use of self-harm. We know, for example, that when we are injured, our body releases a variety of chemicals to help us cope with the pain. Naturally occurring opioids and other pain relievers are made in our body to help us deal with pain. Moreover, as with fingernail biters, some pain also releases serotonin in the brain. Therefore, if the chemical goal is to relax and find calmness, increasing serotonin, the main chemical target for medication treatment in depression, could help.

In sum, it is likely that self-harming offers some mild, though temporary relief in symptoms. Though certainly a dangerous and maladaptive means of doing so, it may in fact offer some respite for these teens.

What Do We Do About It?

Responding to self-harming behaviors is difficult. You want to, simultaneously take these actions seriously though not overreact. Dismissing the behaviors will certainly lead to their ongoing presence. While overreacting could increase the teen’s attempts to hiding the behaviors. Either way leads to more problems.

Many parents respond with anger and frustration. These parents, admittedly out of fear, may angrily ask, “What are you doing?!? Why would you do this?” This, of course, will likely close any door of communication between them and the teen.

Other parents respond in an intensely emotional way. They will start crying and overwhelm the teen with attention and appointments with pediatricians, dermatologists, psychiatrists, and counselors. They will not allow the teen to be alone and overtly lock all of the kitchen knives in their bedroom. While this response includes many of the appropriate steps, the flood of focus tends to be too much for the teen, as they are often forced to retell their story to each professional. Not to mention all of the responses they tend to get from extended family members, who find out about the issues as the parent seeks support. Again, this type of overreaction will likely lead to more overwhelming feelings and problems.

The most appropriate response to discovering your child is using self-harm as a tool for emotional regulation is to – as best you can – remain calm. Listen to them. And don’t overreact. Reassure them that you want to help and that you hear their pain. Tell them that you will schedule an appointment with a professional, and have your teen help you pick one out. The type of relationship and connection your teen can have with the first therapist he/she sees sets the stage for success. So ask him/her if he would prefer a counselor who is male or female, younger or older. Some teens prefer to see someone that one of their friends sees; while others prefer to see someone in the next town over, to formalize a separation between “real life” and the struggles discussed in therapy.

Responding to these issues is tricky. Although most teens who cut deny any suicidal intent, many will admit some thoughts about suicide – noting the important difference between suicidal thoughts and suicidal intent. A very high percentage of teens have had suicidal “thoughts” but have never had suicidal “intent.” Nonetheless, the risk of cutting “too deep” is always present, especially when cutting during a time of heightened emotions.

Many parents question whether they should take their teen to the hospital. Here in Florida, the Baker Act is used to involuntarily hospitalize a person who is deemed a danger to himself or others. The Baker Act, which allows hospitals to hold a patient involuntarily for up to 72 hours, is often used for those who are actively suicidal or who are behaving in erratic, unpredictable, and dangerous ways.

For many teens who cut, this is not an appropriate response. They are not suicidal, and although they are – technically – hurting themselves, there is no intent to cause life threatening injury. In such a case, having the child Baker Acted could cause more problems by feeding mistrust and, in many cases, unnecessarily scaring the teen.

The problem, though, is knowing who needs such attention and who doesn’t. How do parents know if they should take their teen to the hospital or try to get the next available appointment with a mental health professional?

The best way to know, as I mentioned before, is to listen. Ask the question, but then listen to what your teen says. You can try something like, “I can definitely see that you are in a lot of pain and that you are not sure how to deal with it. Have you had any thoughts or plans of taking it farther? Have you thought about suicide?” And then just wait.

If he does not say anything, say something like, “Honey, I know that sometimes my thoughts take me places I don’t want to be. They make me think things that scare me. Is that happening to you? Are your thoughts taking you to a place where you have thought about suicide?” These simple statements let him know two things. First, that these thoughts are not necessarily his own. And second, that you understand that his thoughts may get out of his control.

As you gently talk to him, stay calm. There is no rush here. It is not likely that he will sprint into another room and hurt himself right in front of you. Remain calm and talk. Ask him if he needs to talk to someone immediately. If you decide that you need to take him to the hospital, make sure he knows that it is simply to keep him safe. And prepare him. Tell him that he will likely sit in the emergency department for a while and talk to a few people. He will then make it to the adolescent unit where he will be assigned a room/bed and will be with other teens who are struggling as well. Help prepare him so that it will not be such a shock. Do not, however, paint a rosy picture of the situation. Do not tell him that it will “be like staying in a hotel for a few days” or that “they will make it all better.” Because it isn’t, and they won’t, not completely anyway. If you tell him that and then his experience is different, he will not trust you next time.

If he is not suicidal, agree to schedule him with a mental health professional for him to talk to. As mentioned before, get him as involved in the decision making as he would like. If he does not care, that’s fine, too. Don’t pressure or push. The ultimate goal is to get him the help he needs.

As a psychologist and a parent, I know that this is a terrifying and intimidating situation. But our children respond to stress in ways similar to us. If we become hysterical, they will too. If we show terror, they will feel it as well. So stay calm, follow these steps and then be as supportive as you can. Together, you can make it through this.

For more information about self-harming, check out these resources and listen to The Mental Breakdown podcast Episode 53, where we discussed self-harming behaviors.