Society is used to the idea of ‘teenage rebellion’: the expectation that adolescents engage in risky behaviours such as binge drinking, substance misuse and unprotected sex. We are less accustomed to noticing the more ‘hidden’ problems, such as depression and self-harm. In fact, whilst teens are turning away from alcohol and drugs, it appears that they are increasingly turning to self-harm as a way of coping with and expressing their distress. Amongst professionals working with young people, self-harming behaviours are eliciting increased attention and concern, with recent estimates suggesting that 27.6% of European adolescents self-harm (Brunner et al., 2014),
As many countries continue to feel the squeeze of the global economic crisis, spending cuts to public services mean that schools will often be the first port of call for many young people who are self-harming. Increasing awareness amongst parents and school staff about which children might be most at risk, and understanding why young people engage in these behaviours, is a crucial step in tackling this growing problem.
What is self-harm?
Self-harm refers to any behaviour that is intended to cause deliberate hurt to your own body, with cutting being the most common method, although others include burning, stabbing, banging heads and other body parts against walls, hair-pulling and biting. ‘Self-poisoning’ refers to overdosing on prescription medication, or swallowing a poisonous substance.
European countries tend to use the term ‘deliberate self-harm’ (DSH) to include any such behaviours both with and without suicidal intent. Canada and the United States, on the other hand, employ the term ‘non-suicidal self-injury’ (NSSI) to explicitly exclude behaviours with any level of suicidal intention.
Whatever the definition being used, it can be helpful to take the view of self-harm as a continuum of behaviours, ranging from those which have a strong suicidal intent (e.g. some types of over-dose), to behaviour which is a coping strategy intended to help the person stay alive (e.g. cutting).
Myths about self-harm
Unfortunately many people working with young people have unhelpful misconceptions about those who self-harm and why. Many see self-harm as a problem of teenage girls who do it to get attention, and even enjoy doing it. This fosters a blaming and unsympathetic stance, which is unlikely to be helpful for the young person in question, who is in need of help. Another damaging misconception is the belief that by asking a young person about self-harm or suicidal thoughts, you can put the idea in their head. This means that the problem is ignored, and may worsen, when it could have been addressed and dealt with.
Understandably, self-harm is a difficult topic, and it can elicit a great amount of fear in those close to the person. Whilst self-harm is a serious issue, it is also important not to jump to conclusions about the person being a great danger to themselves and therefore in urgent need of hospitalisation. Although some forms of self-harm do carry a serious risk, this doesn’t mean that someone who self-harms is always intending to cause serious injury. Equally, just because a wound that isn’t “that bad” doesn’t mean that the underlying problem is not serious. Clearly a balanced and individualised approach is needed, as the motivations and methods for self-harm will differ from one person to another.
So who self-harms?
The short answer is that anyone can self-harm. This behaviour is not limited by gender, race, education, age, sexual orientation, socio-economics, or religion. However, there are certain factors that can increase a person’s risk of engaging in self-harm. Vulnerable groups include female adolescents, lesbian, gay, bisexual and transgender people, young people with a friend who self-harms, and young people who have experienced physical, emotional or sexual abuse during childhood.
Figures suggest that female adolescents are four times more likely to have self-harmed in the previous year than males (Madge et al., 2008). However, it is also likely that boys engage in behaviours such as punching a wall rather than cutting, which others are less likely to recognise as self-harm.
Interestingly the issue of self-harm appears to be a growing concern amongst students from middle and upper class backgrounds. The Headmasters’ and Headmistresses’ Conference (HMC), which represents 275 private schools in the UK, reported a 57 % increase in schools reporting incidents of self-harm between 2010 and 2015. Increases in exam pressures and the influence of social media have been thought to play a role.
Despite these trends, stereotyping must be avoided, as in reality self-harm doesn’t happen to one type of person, and it is difficult to get accurate prevalence estimates.
Why do people self-harm?
Most young people self-harm as a way of coping with overwhelming painful and difficult feelings, as they don’t know how else to deal with them. Reasons cited by young people for their self-harm include daily stresses such as feeling isolated, academic pressures, family breakdown, suicide or self-harm by someone close to them, and low self-esteem or poor body image (Mental Health Foundation).
Self-harm in the majority of cases brings about “relief from a terrible state of mind” (Madge et al., 2008), although other common reasons include “I wanted to punish myself” or “I wanted to die”. Less common reasons are “I wanted to get back at someone” or “I wanted to frighten someone”. Common precipitants of any individual act of self-harm include arguments with a partner or close friend, family arguments, intoxication, or an incidence of bullying or abuse.
Because young people often find release in self-harm, it can be difficult for them to envisage coping with life without it. However, self-harm is clearly not a good way of dealing with problems, as (beyond the obvious physical damage) the relief very short lived, which causes individuals to do it many times, and it does not deal with the underlying issues.
How can you know if someone is self-harming?
Self-harm can be difficult to spot as it rarely occurs in a public setting, and individuals usually make an effort to conceal any wounds that they may have inflicted on themselves. Staff working with young people should pay attention to any secretive behaviours, such as spending unusual amounts of time in toilet facilities or other isolated areas. Additionally, looking out for any student who consistently wears clothing designed to conceal wounds that often appear on the arms, thighs or abdomen is recommended. For example, consistently wearing long sleeved clothing in hot weather, or refusing to engage in activities that would mean exposing affected parts of the body, such as swimwear or sports kit. Frequent unexplained bruises, scars, cuts or burns may also be evidence of self-harm. Given the known environmental and psychological risk factors, special attention should be paid to individuals who are experiencing bullying, family breakdown, or showing signs of depression, social isolation or low self-esteem.
What to do if you think someone is self-harming?
Whoever suspects that a young person is self-harming should be able to talk and listen to him or her, in an open and non-judgemental manner. This is unlikely to be an easy conversation to have, and it’s important that teachers and other relevant persons know the “do’s and don’t’s” of how to handle such situations:
Do’s:
- Approach the student in a calm and caring way
- Understand that this is a means of coping with difficult feelings
- Accept him or her, though you may not accept the behaviour
- Refer the student to the school based professional
- Listen and be available
- Help the student discover and use their personal strengths
Don’t’s:
- Say anything to cause the student to feel guilt or shame (e.g. “why would you do this to yourself?”)
- Act shocked or appalled by the behaviour
- Talk about the self-harm in front of the student’s peers
- Try and teach the student what you think he or she should do
- Judge the student
- Tell the student that you won’t tell anyone if he or she shares information about the self-harm to you, as it’s your duty to inform relevant others to protect the child from harm
(Adapted from Lieberman et al., 2009)
Teachers and other staff working with adolescents should know that they are unlikely to stop a student from self-harming, and understand that their primary role is to ensure that the young person is seen by an appropriate professional (e.g. the school counsellor).
Interventions for self-harm
Although there are no specific guidelines for the psychological treatment of self-harm in adolescents, best practice is for the young person to have a detailed individual assessment by an appropriate professional within a mental health setting. The aim of this would be to gain an understanding of the self-harming behaviour, including the intention of the behaviour and the expected consequences. Details such as the individual triggers, the method used, whether it happens alone or with others, can be helpful for informing the intervention. Additionally, ascertaining the young person’s individual circumstances (such as areas of stress and worry) are important. Given the personal nature of self-harm, and the reasons for it, it is best practice for a young person to be seen alone.
Depending on the outcome of the assessment, the young person can then be referred for therapy to address their particular needs, which may be the self-harm itself, or other underlying mental health difficulties such as depression.
The psychological therapies with the largest evidence bases for the treatment of self-harm and related difficulties are Dialectical Behaviour Therapy (DBT) and Cognitive Behaviour Therapy (CBT). Both types of treatment would aim to increase the individual’s ability to manage difficult emotions, by helping them to make sense of their difficulties, drawing upon their individual strengths and reinforcing more positive coping strategies. These therapies would also aim to enhance particular coping skills with respect to tolerating distress and problem solving. It is often possible for carers to be involved in the therapy to a varying degree, so they can understand how best to support the young person.
A word of warning about social media websites
One explanation for the growing numbers of self-harming adolescents has been social media websites. Not only has social media recently been connected to symptoms of anxiety and depression (risk factors for self-harm) but many sites have been associated with the promotion of self-harming behaviour. Even though sites such as Facebook, Instagram and Tumblr work hard to remove such content, they are unable to prevent some of their users temporarily sharing pictures of their self-harm and sometimes even giving instructions to others about how to do it. Colleagues who work with adolescents who self-harm have found that for some young people, seeing such images or posts can indeed trigger them to self-harm. Unfortunately, even forums that are intended to provide peer support, such as recovery blogs, can have this effect. Parents and teachers should therefore be aware that sites where teenagers are connecting with others who share what they are going through can be a very powerful influence, and unfortunately not always for the good.
Thankfully, with increasing understanding and awareness, more young people are able to access the help they need. The many pressures of adolescence require effective and flexible coping strategies. If you think someone might be using self-harm to deal with difficulties, please don’t ignore it. With the right support, many young people successfully manage to adopt more positive and constructive means of coping, paving the way for a bright and balanced life.
About the author
Georgie Bremner is a Clinical Psychologist in training in London, who has worked with adults diagnosed with ASD who have mental health difficulties, using adapted Cognitive Behavioural Therapy. Georgie’s first degree was in Psychology, Physiology and Philosophy at Oxford University, where she was awarded the British Psychology Society undergraduate award for obtaining the highest mark in an accredited Psychology programme. Georgie’s main research interests are in the development and treatment of anxiety disorders, notably social anxiety disorder and post-traumatic stress disorder.
Key references
Brunner, R., Kaess, M., Parzer, P., Fischer, G., Carli, V., Hoven, C. W., … & Wasserman, D. (2014). Life‐time prevalence and psychosocial correlates of adolescent direct self‐injurious behavior: A comparative study of findings in 11 European countries. Journal of Child Psychology and Psychiatry, 55(4), 337-348.
Lieberman, R., Toste, J. R., & Heath, N. L. (2009). Nonsuicidal self-injury in the schools: Prevention and intervention. In M. K. Nixon & N. L. Heath (Eds.), Self-injury in youth: The essential guide to assessment and intervention (pp. 195–215). New York, NY: Routledge Press.
Madge, N., Hewitt, A., Hawton, K., Wilde, E. J. D., Corcoran, P., Fekete, S., … & Ystgaard, M. (2008). Deliberate self‐harm within an international community sample of young people: comparative findings from the Child & Adolescent Self‐harm in Europe (CASE) Study. Journal of child Psychology and Psychiatry, 49(6), 667-677.
Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health, 6(10), 1-9.
Truth Hurts (2006) The final report by the National Inquiry into self-harm www.selfharmuk.org
http://www.mentalhealth.org.uk
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