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Mary's Story

Mary is a 14-yo teenager who has always been somewhat quiet and shy, so her mother was surprised when she found out that Mary started dating a boy this school year. But lately, Mary's been a lot moodier than usual. And just the other day, Mary's mother caught a glimpse of Mary's forearms and saw that they had scratches and cuts all over them. Like most parents would feel in such a situation, Mary's mother felt suddenly scared and confused, and thought to herself "This is terrible! I've no idea how to deal with this! What am I supposed to do!"

What is Self-Harm?

Self-harm is the deliberate attempt to harm oneself and in most cases, is done without consciously trying to end one's life. (The official term is non-suicidal self-harm (NSSH)). 

The most common type of self-harm behaviour is self-injury, which is the deliberate damaging of one's body, such as by self-cutting; scratching or burning one's skin, "minor" overdosing of medications (taking excess amounts of medications but not enough to kill oneself) and banging one's head against a wall.

Who Self-Harms?

Self-injury behaviours start on average at age 15, and is most commonly seen in teenagers and young adults. In one study of Canadian youth aged 14-21, 17% were shown to have self-harmed, and it is twice as common in females (21%) than in males (8.7%) (Nixon et al., 2008).

Why Do People Self-Harm?

It is believed that people self-harm in order to regulate how they feel, such as coping with stress (or boredom). People who self-harm often report they do so in order to: 

• Get relief from painful or distressing feelings; 
• Deal with feelings of numbness or loneliness;
• Communicating pain or distress to others

Although self-harm is not the healthiest way to achieve these goals, all of these goals are actually quite healthy. 

How You Can Support a Child/Youth with Self-Harm: Short-Term

Do's

• Express that you care for the person behind the self-injury "I love you and I'm worried about you."

• Acknowledge that the person may be under stress or feeling extremely distressed

• Ask, "How can I be helpful?" or "How can I support you?"

• Suggest distractions as alternatives to self-harm. Although distractions are not a long term solution, they can help in the short-term.

Some Self-Soothing Strategies include:

• Learn basic First Aid to know how to deal with any cuts or self-injuries. For minor cuts or injuries, wash them with mild soap and water so that they don't get infected. For more serious cutting that may require professional medical care (such as stitches), offer to take your child to the nearest walk-in clinic, doctor's office, or hospital emergency room.

• Let the person know that if and when they want to talk about their self-harm (and stress), that you are ready to listen without judging.
  
  You might say: "I'm worried about you. If there's something you want to talk about, let me know. I promise I'll listen, and I won't get upset or angry at you, no matter what it is. I love you no matter what."

Don'ts

• Don't try to make the person guilty or ashamed; don't show disgust or revulsion at the person. Making the person feel guilty or ashamed does not usually help. Worse, you may end up making them feel bad about themselves, which usually leads to the person not wanting to trust you or be with you.

• Don't simply tell the person to stop self-harming. Self-harm is a way of coping; simply taking away the person's coping strategy without offering an agreed upon alternative can even be dangerous because then the person may act on impulses to end his/her life. In the least, it can end up making the person distrustful of you.

How You Can Support a Child/Youth with Self-Harm: Long-Term

Do's

• If your child/youth is calm enough, then consider problem-solving
  • Note that this can only be done if the person is in a calm state. If a child is not open to your suggestions, consider trying other strategies that focus on supporting the person until they are calmer. 
     
• Identify the stressors
  • Ask the young person what stresses s/he is under that might be contributing to the cutting

    • Adult: "Any idea what makes you feel that like hurting yourself?"

  • If your child responds, "I don't know!", you could say:
    • Adult: "Normal stresses people have include school (like teachers, school work and classmates), home (like your brothers/sisters and parents), or friends (like boyfriends and girlfriends)."
  • Then you might say
    • Adult: "So how are things at school? How are the teachers? How's the school work?, etc..."
• Try to help the young person problem-solve whatever the stress is

Be an Authoritative Parent with "Love and Limits"  

Regardless of what stresses led to the self-harm, certain parenting styles appear to be more helpful in supporting a child with self-harm. Parenting styles that are at the extremes may contribute to stress for not only youth, but also for parents. The challenge is to find balance between the two opposing extremes (Miller et al., 2007).

Extremes and Dilemmas in Parenting

It is recommended to try to find an "authoritative" balance, which means:

1. Give your child guidance and rules so s/he can figure out how to be responsible,
2. Give your child greater amounts of freedom as s/he is able to demonstrate responsibility, and
3. Spend time with your child (by talking, doing activities, or just hanging out) to ensure a healthy relationship.

Dealing with Threats to Self-Harm

Its only human nature that some youth who self-harm may try to use it to ask for more privileges, or to escape consequences.

E.g. the young person may say, "I'm going to feel depressed and cut myself if you don't let me go out to that sleepover at Melissa's this weekend."

If you are feeling manipulated into doing something unreasonable, then ask yourself, "What would be normal rules and limits for any other child?"

If you feel your rules are reasonable, then don't give in and do what s/he is asking for. By giving in, you end up supporting the unhealthy part of him/her.

As the responsible parent, you might say something like: "I'm sorry if you don't agree, but it's perfectly reasonable to expect you to be back by curfew time. It wouldn't be healthy for you if we didn't have reasonable rules."

At the same time, if your child truly is feeling overwhelmed from having too many expectations, it makes sense to temporarily reduce those expectations. E.g. you might say, "I appreciate that you're a bit overwhelmed these days. So how about this - instead of having to take out the dog every day and do the dishes, you only have to do one of those things for the time being. You can choose which one you want to continue doing for now."

When to Get (Professional) Help

Often times, families can learn ways to help their child deal with self-harm.

But if you do have concerns (e.g. such as if your loved one's self-harm is not getting better), consider taking your child to see a health professional such as the child's primary care provider, a children's mental health agency, or a mental health professional (e.g. social worker, psychologist). 

In emergency situations, contact a telephone crisis line, or local hospital emergency room. 

Treatments for Self-Harm 

Various types of treatment interventions have been shown effective for deliberate self-harm as well as suicidal behaviours such as:

• Dialectical Behaviour Therapy (Linehan, 1993) and
• Cognitive Behavioural Therapy (Slee, 2008).  

Slee describes a "vulnerability-stress" model to explain self-harm (Slee, 2008):

1. Vulnerable person: Self-harm is more likely in a person who is vulnerable (such as someone who has a brain wired to be more sensitive emotionally (so-called 'orchid children'); history of negative childhood or life experiences; family history of similar difficulties.

2. Stress: The vulnerable person encounters a stressful incident or situation.

a) Typical (external) stresses are:

• School (teachers, schoolwork, peers),
• Relationships (boyfriends, girlfriends, friends, parents, siblings).
• Home (dealing with parents, situations such as divorce/separation or living in foster care or a group home, conflict with siblings)

b) Typical (internal) stresses include having to deal with, control or regulate one's feelings:

• Dealing with a lack of feelings, e.g. "To deal with the emptiness"
• Dealing with too much (distressing) feelings such as anger, anxiety or depression, e.g. "Cutting helps me turn the emotional pain into physical pain"

3. Unhealthy thoughts: The triggering stress leads to unhealthy thoughts, e.g. "No one loves me", "Nothing's going to get better", "There's nothing I can do"...

4. Self-harm behaviour: because the person has unhealthy thoughts, or is simply overwhelmed, this leads to the self-harm behaviour.  The person using self-harm is doing so because s/he is overwhelmed and has not yet been able to learn and use healthier ways to cope.

The more often someone harms him or herself, the less the behaviour is linked to external events and the easier his/her own thoughts can become triggers for self-harm (e.g., "No one cares about me") (Slee, 2008).

Common elements addressed in various treatments include

1. Helping the person identify what stresses they are under that might be contributing or triggering self-harm
2. Improve problem-solving: helping the person find better ways to cope such as using a) distractions, or b) ways to address and deal with the stressful situation
3. Problems with emotion regulation: helping the person identify their feelings, and find healthier ways to deal with them (e.g. "I need a warm hot bath and then I'm going to sit in a rocking chair reading a favorite book")
4. Dysfunctional thoughts: helping individuals identify their dysfunctional thoughts (e.g. "nobody loves me") and replace them with more positive ones (e.g. "its okay, I can get through this")
5. Interpersonal skills: helping individuals communicate better so that they can deal with stresses with others, as well as get support from others, rather than having to use self-harm

 "What's Happening with Mary?"

After seeing the cuts and scratches on Mary's arm, Mary's mother wasn't sure what to do.

Mary could see her mother was upset and broke down crying.  "Mom, I would have told you sooner, it's just that I thought you'd get angry at me."

Mary's mother didn't know what to say at first, so she just looked at Mary and gave her a hug.  "Mary, I love you. Whatever it is, we'll get through this. Now tell me what's been going on..."

Mary told her mother about the stresses she'd been going through. Her mother called the local crisis line and spoke with a crisis counsellor who asked mother some additional questions to make sure that Mary would be safe that night. (Had there been concerns, Mary's mother would have taken Mary to the local hospital Emergency Room, or called 911). The crisis counsellor gave them a number of a local children's mental health agency to call the next day. Just to be sure, Mary's mother also booked an appointment with her family doctor the following week.

Mary eventually started to see a mental health professional, and received counselling and therapy.  Together, they worked on helping use healthier ways to cope with her stresses and manage her emotions. Its now several months later and summertime and Mary is wearing T-shirts again...

Summary

Self-injury behaviours may be seen in teenagers and young adults as a way of coping. Fortunately, there are many ways that professionals and parents can help support their children and youth to help them cope better. 

References

Miller, A.L., Rathus, J.H., & Linehan, M.M. (2007). Dialectical behavior therapy with suicidal adolescents. New York: The Guilford Press.
 

Nixon, M.K., Cloutier, P., & Mikael Jansson, S. (2008). Non-suicidal self-harm in youth: a population-based survey. Canadian Medical Association Journal, 178(3): 306-312.
 

Slee, N., Garnefski N., van der Leeden, R., Arensman E, & Spinhoven, P. (2008). Cognitive-behavioural intervention for self-harm: randomised controlled trial. British Journal of Psychiatry, 192:202-11.
 

Whitlock, J., & Knox, K.  (2007).  The relationship between self-injurious behaviour and suicide in a young adult population.  Archives of Pediatric Adolescent Medicine, 161(7): 634-640.

About this Document

Written by members of the Mental Health Information Committee at the Children’s Hospital of Eastern (CHEO) and by members of the Child and Youth Mental Health Information Network (www.cymhin.ca). Special thanks to Sylvia Naumovski and Sarah Cannon, Parents for Children’s Mental Health (www.parentsforchildrensmentalhealth.org). Special thanks to Parent's Lifeline of Eastern Ontario (PLEO).

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance. 

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