A common question in our community is about the connection between self-harm and suicide. Self-harm, also known as Non-Suicidal Self Injury (NSSI), is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as relational and coping. Self-harm as a means for suicide can be described as one of eight possible reasons for engaging in self-harming behaviors. Dr. Jack Klott discusses the eight reasons in detail in his online series, Suicide and Self-Harm: Stopping the Pain as:
1. Emotion regulation or coping-i.e. to calm the senses
2. Self-punishment- i.e. “I deserve to hurt.”
3. Psychosis-i.e. command hallucinations to harm self
4. Response to anxiety and depression- i.e. to bring back into body, to feel something, to express internal pain
5. Peer influence- i.e. they said it worked for them
6. Body dysphoria- i.e. I need to alter my body to feel more like myself
7. Isolation and abandonment- i.e. expressing pain
8. Suicide rehearsal- i.e. intention to die
For teens today, any of these eight possibilities could apply. Although each person has their reasons for engaging in self harm, more and more teens are going to their peers and the internet for answers on how to handle the stress they face in academics, relationships, and more.
For 12-year-old Savannah, for example, self-harm patterns in her life are the result of a friend saying it helped them cope, therefore encouraging Savannah to explore if self-harm would have the same results for her as a coping strategy.
What and Where?
So what does self-harm look like for today’s youth? In the clinical arena, we are tracking trends in behaviors that have been socialized and publicized to some degree, like the Tide Pod Challenge of 2018 and the Salt-Ice Challenge of 2012. According to the Mayo Clinic, self-harm can be defined as any behavior that is self-inflicted, deliberate, and results in injury. Examples could be scratching, cutting, burning, hitting, and rubbing the skin until it’s damaged, as is the result of using an eraser on the skin. As more awareness is built around self-harm, the once typical locations of arms and legs may be seen as too noticeable to the public eye by individuals who feel a sense of judgement or shame after having engaged in self-harm behaviors. Therefore the clinical community is now tracking self-harm that appears more subtle when expressed on the human body, such as locations that are easier to cover up or hide from others, including but not limited to armpits, torso, upper thighs, and between toes.
Curiosity and Compassion
Engaging youth in exploration as to what purpose the behavior serves can bring context and understanding to their reasons for engaging in repeat self-harming behaviors. It can also help professionals, family, and friends identify appropriate responses to self-harm in order to best support of the person they are trying to help. Asking questions from a neutral, curious place can clarify a youth’s choice for self-harm as it relates to risks for suicide.
Examples of how to ask:
“What purpose does this serve for you?”
“What do you get from engaging in self-harm?”
“What was your intention when engaging in self-harm?”
For example, after being encouraged by her peers, 12-year-old Savannah states that she scratched her arm repeatedly in trying to cope with an internal, painful experience. This disclosure may feel very different in how a professional would respond to safety needs in comparison to the experience of 22-year-old Taylor, who reports he was hoping he would get an infection as the result of self-harm and die.
Harm-Reduction Model
Self-harm can be considered a precursor and risk factor for suicide, which is why it is important to explore a person’s experience and purpose for engaging in self-harm behaviors. Best practice continues to be a Harm Reduction Model when it comes to addressing self-harm behaviors, which means working alongside the person to identify other coping skills that could be utilized prior to self-harm with the hope of the urge dissipating as time passes and other strategies are utilized. The peak of strong emotions and stress is best described as the bell curve, where once a person in distress reaches the peak and start moving back to baseline—possibly out of fatigue or exhaustion—individuals who have historically engaged in self-harm report they are less likely to engage in the behavior in feeling less of a pull to do so.
Coping skills that can reduce the intensity and frequency of self-harm should be unique and individualized to each person. Returning to 12-year-old Savannah, for example, with therapeutic support, she has identified that she is looking for external expression of internal pain. Therefore, the primary theme for Savannahs’ safety plan would be to support her in identifying other ways to express that pain. For some youth, just the sight of damaged skin or blood is sufficient to shift or alleviate their current state of pain. For these individuals, a mental health professional might work with them to try fake blood applied to their body where they feel the urge to self-harm, or other expressions such as henna tattooing or doodling.
For individuals who report that the pain response is the key element that quiets their internal system, other means can be introduced that reduce the risk of injury or infection. For example, perhaps a mental health counselor introduces a rubber band for youth to snap their own wrist, a frozen washcloth to pull apart that results in intense cold and stinging without injury, or introduces Icy-Hot for the tingling sensation on their skin. Again, each person’s Harm Reduction Plan should be catered to their needs in support of reducing self-harm behavior by means of how often they engage in the behavior and reducing methods that increase suicide risk.
