Self-Harm: Identifying and Supporting Teens Who Intentionally Hurt Themselves

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For some students, stresses in their lives can lead to dangerous behavior, such as intentional self-injuries

Juliana Kerrest started hurting herself when she was 13 years old. Juliana said the first time it happened was almost ““an accident.”  Juliana, who had suffered from depression since she was 10, was upset, noticed a toothpick nearby, and began scratching herself with it, “without thinking” about it.  Over time, the scratching turned into cutting, and then progressed to burning and hitting. In high school, Juliana cut herself several times per week, sometimes more than once per day. In college, her self-injuries were less frequent but more severe. She bears the scars today.

Juliana, now 27, said that in middle and high school the cutting was a way to express anger and punish herself, but in college she used it as a way to “snap out of” feeling depressed, dazed or unable to focus. But during all of the years she was hurting herself, not a single adult who she hadn’t already told about her problem saw the marks and asked about them.

Juliana, who attended a boarding school for most of high school, said that she went to great lengths to hide her injuries, but at the same time, was angry and upset that her teachers and peers weren’t able to see through the “happy face” she put on. She would have liked to be able to show her injuries to other adults in her life, she said, because they were proof of the turmoil she was going through. She remembered wishing that she would accidentally not roll down her sleeves quickly enough, so someone would ask her about the marks. (Juliana said that in warm weather she would cut her upper thighs, sides or shoulders so her cuts would be covered by her clothing.)

When asked about adults who did support her during her recovery, Juliana repeatedly mentioned her school advisor. He was “very nonjudgmental about it,” said Juliana, so she knew she could talk to him, and he would keep it confidential and not use it against her. He checked in with her to make sure she was talking about the issue with her therapist, and really listened to her, she recalls. Today, Juliana has a full time job as an account manager for an Internet company and is also a member of the Active Minds Speakers Bureau, talking to college students and other audiences about mental health.

Adolescence is a tumultuous and often challenging time for all young people, but for up to 21 percent of high school students, the stresses in their lives can lead to dangerous behavior, such as intentional self-injuries. These youth “are dealing with intense feelings or conflicts that they aren’t finding a healthy outlet for,” said Dr. Steven Israel, medical director of Adventist Behavioral Health in Rockville, Md., and a board member for the Adolescent Self Injury Foundation.

“Self injury … is a symptom that may or may not mean something more dangerous is going on psychiatrically,” said Dr. Israel, comparing it to chest pains, a symptom which could indicate a heart attack, or something much more benign. Self-injury can be a way for young people to cope with feelings of anger, shame, self-blame or self-loathing. When these feelings progress to the point where a teen is physically harming himself or herself, an evaluation by a mental health professional — who can determine severity and underlying causes, and develop a treatment plan — is necessary, Dr. Israel explained.

A study reported in the journal “Pediatrics” in 2012 interviewed youth in third, sixth and ninth grades, and found than an average of 8 percent reported engaging in self-harm without suicidal intent. Ninth-grade girls were the most likely to engage in the behavior, with 19 percent saying they had harmed themselves. The article also referenced previous studies reporting higher rates of non-suicidal self-injury (NSSI) among older youth, ranging from 14 to 21 percent among high school students, and up to 38 percent of college-age students.

Research finds even greater numbers when looking at studies of youth in institutional settings, such as residential treatment or detention facilities, or who have had some mental-health diagnosis and/or treatment, said Dr. John Peterson, senior instructor in the department of psychiatry at the University of Colorado School of Medicine.

Although the public and/or practitioners may hear more about self-harm or feel like they are seeing more kids who are cutting, it’s unclear if this behavior is actually increasing, says Peterson. (See Non-suicidal Self-Injury, What the Research Says — and Doesn’t)

Cutting, usually with a razor or other sharp object, and burning (including friction burns created by rubbing with erasers or other tools) are among the most common types of injuries according to Dr. Peterson, although he said most youth who engage in this behavior report using different methods at different times. Such self-harming behavior most commonly starts between ages 12 and 14.

Youth service providers can help

Professionals and volunteers can help young people they work with by recognizing and responding to signs that teens are troubled. Mitru Ciarlante, director of child and club safety for Boys & Girls Clubs of America, said most Clubs have annual safety trainings which cover recognizing youth risk behaviors, victimization and abuse, as well as other indicators young people are experiencing distress. Some Clubs may also offer more in-depth training on resilience, suicide and other mental health-related issues, which can include recognizing signs of self-injury and identifying youth who need assistance beyond traditional club programming.

Ciarlante explained that some youth face particularly difficult situations at school, at home and in their communities while they are also dealing with the normal turbulence of adolescence. A youth-development professional who has an ongoing rapport with a young person is in a good position to recognize where he or she may be struggling to cope, and can reach out to offer assistance, said Ciarlante.

“Sometimes we may see a young person struggling, but we don’t know if the issue is feelings of self-harm, domestic violence or something else,” said Ciarlante. “We need to connect with that young person, to find out what’s going and what they need.” The strategy — and BGCA’s training mantra — is the same in any of those cases: “recognize, respond and report or refer.” (See HERE for more information of recognizing signs of self-harm, responding to them, and bringing in additional help through reporting and referrals.)

Taking action to help

Once an adult suspects or knows a young person is intentionally injuring himself, it’s important to address the behavior. Peterson cautioned against simply dismissing self-harm as an attempt to be provocative or gain attention, explaining that this behavior is a serious concern, requiring empathy from parents and professionals, as well as a mental health evaluation and possible follow-up services.

In trainings, staff can roleplay to practice these sometimes-difficult conversations. Both Israel and Ciarlante suggested asking the teenager how she is doing generally, before asking about self-harm specifically. They also suggest telling the young person what you’ve noticed (such as talking less, or marks on the arm), and explaining that you are concerned. “It can be really hurtful for a young person to feel like they are putting out signs and no one notices or asks about it,” said Ciarlante, who added that disclosure is a process and young people may not be willing to discuss it the first time someone asks.

Peterson also said studies show that empathetically asking a young person questions about self-injurious behavior does not make them more likely to do it again, or add to their stress.

Holding one-time workshops or assemblies to raise awareness about self-injury can be an issue, however. These types of efforts are “at best, either not effective or only effective in raising short-term knowledge and are, at worst, linked to increases in the behavior they intend to stop,” according to the Cornell Research Program on Self-Injury and Recovery (Cornell). Cornell also cites research showing that self-harm can have a “contagion” effect, causing the behavior to spread among youth in communities such as schools, hospitals or detention facilities, and mentions that the prevalence of self-injury in media may also be a factor in its spread.

Support staff to support youth

In training staff to respond to teens’ self-harm behaviors, Ciarlante suggested underscoring urgency and encouraging them to reach out to supervisors or co-workers rather than minimizing their concerns. “If it comes to the attention of a youth-development professional that a youth is struggling to cope to the point that an injury is happening, we need to get outside help,” she said.  Some self-harm goes on for a long time as a coping mechanism, she said, but some escalates into more risky behavior, so early intervention is important.

Ciarlante recommended that youth-development professionals who recognize that a child is using self-injury call a community mental health provider who can conduct an emergency assessment, and stay with the young person to provide support while the call is made. She noted that laws about youths’ access to services and consent requirements vary by state and may also depend on the youth’s age or the severity of the crisis. Professionals can call 911 to find emergency help during a mental health crisis, she said. For non-emergencies, see the resources listed in the box below.

Ciarlante also suggested forming working relationships with mental-health providers so you know in advance who can help. When a trusted youth-serving professional is the one to make a referral or introduction to a mental health clinician — and ask about follow up — that relationship can be a bridge to a good rapport with the mental health provider.

Just recognizing and responding to youth who are in crisis is not enough, Ciarlante said. Programs serving young people should help youth build resilience and coping skills as an ongoing part of their work, and create a culture and climate of safety and support.

Although the youth-development professional will not be the one providing clinical intervention, being knowledgeable and supportive of mental-health services is important (see “Understanding clinical treatment”).  Once a young person is in treatment, Dr. Israel suggested other adults in her life avoid becoming anxious or focusing too much on the self-harming behavior, but instead be a sounding board for what’s going on in her life more generally. “It’s important for kids to feel validated; they need to know that their feelings are legitimate,” he explains, adding that simply knowing a caring adult is there for them and able to listen “goes a long way to help.”

 

Additional resources

The Suicide Prevention Lifeline, 800-273-TALK (8255), connects callers to local crisis centers. They can provide guidance and referrals if you are worried about a young person who is hurting herself, regardless of if she has suicidal intent. Its website, suicidepreventionlifeline.org/, also lets you chat online with trained crisis counselors who can help.

The Substance Abuse & Mental Health Services Administration offers an online directory (searchable by city or zip code) of mental health provider facilities at 1.usa.gov/SFSJVw.

Additional information on adolescent self-injury is available from the National Alliance on Mental Illness and from the American Academy of Child & Adolescent Psychiatry.

The Cornell Research Program on Self-Injury and Recovery offers information on prevalence and causes of, as well as responses to self-injury at selfinjury.bctr.cornell.edu

Active Minds (activeminds.org) is a grassroots mental health advocacy organization that raises awareness about mental health issues through its chapters and events on college campuses, as well as its speakers bureau and other national programming.

 

Lisa Pilnik, JD, MS, is a freelance writer, consultant and co-founder of Child & Family Policy Associates, a Maryland-based consulting firm.