Article three in a series of three about self-harm.
Self-Harm is an increasingly pervasive symptom of emotional distress among adolescent girls. Because it involves physical damage to the sufferer, cutting understandably evokes distress and fear in others. Viewed on a continuum, self-harming behavior can easily (though not always accurately) be interpreted as a precursor to suicidal behavior. Because self-harm is so pervasive and so disturbing, InnerChange program director Dustin Tibbitts, LMFT, has written a three part series to help parents better understand and address this behavior.
With the epidemic in cutting that has erupted in the past several years, adolescent therapies (and therapists) have had a tough time keeping up. There are, however, a number of tried and true, research-supported approaches to therapy that can help adolescents manage and overcome the impulse to cut or self harm.
Safety First
Before therapy can really begin, it’s critical to create situation where the adolescent is physically and emotionally safe. Relationships free from abuse and neglect are paramount in the treatment of self-harmers. Before assisting a girl with her self-harm, we must assess whether or not she is safe in her current situation. If she is not, the concerned therapist, friend or caregiver must report the abuse or neglect to the proper authorities and obtain professional counseling for the adolescent.
Secondly, we should make the home and school environment as safe as possible. Through situational planning, we can remove or lock up objects that are too readily available for self-harm, such as shaving razors, kitchen knives, utility blades, and so forth. Some parents find that routine, unexpected room searches or body searches work. It’­s important to note that many of my clients express that they do not like their parents to search their rooms or bodies. However, almost every young woman I’ve spoken to contradicts herself when asked what she would do for a good friend or younger sibling! There must be a balance, and if we can convince the young woman to agree to room searches or body searches, we have made significant progress.
It is wise to remove as many sharp objects as possible, understanding that adolescent self-injurers will harm with whatever is around. Tiny screws in the light switch, a stray staple in the carpet, jagged rocks, and the sharp edges of construction paper; it is impossible to remove all of these from a home or school. So why try? Because therapists, parents and other caregivers send a message of compassion and concern when they remove the obvious, easily-accessible objects. We communicate that we are fully committed to the healing process, and we model safety in our physical surroundings. It sets us up perfectly to move into the most important part of therapy for self-harm: a nurturing, safe relationship.
Love is the Ultimate Motivator: Shaming Has the Opposite Effect
Unfortunately, parents are often so scared by their adolescent’s self-harm that they overreact. When parents overreact, they inadvertently shame their already ashamed child. Their assumption is that their child is going to take the “next step” and commit suicide. It is important to know that self-harm does not always lead to suicidal behavior. However, it is easy to understand why parents’­ initial thoughts may be that their child wants to die, because, according to therapists and researchers, “wanting to die” is one of the top reasons for adolescent self-harm and some even use self-harm as a “practice run” for a future suicide attempt.
When I asked my young friend, Deanne, what advice she had for parents and therapists who are trying to help an adolescent who is struggling with self harm, she said, “. . . You definitely don’t want the person to feel shame about it (cause it will only make them want to do it more.)” She insinuated that the young woman will have yet another reason to want to die.
Honesty, Respect, and Empathy
For some girls cutting is a cry for someone to show compassion toward them. For these girls, psychotherapist and author Steven Levenkron writes, “talk, trust, healthy attachment, intimacy, and secure communication are the necessary building blocks for change.” He is quick to point out that “the prerequisite for the helper is to develop influence with the self-mutilator” and that influence comes from experiencing a trusting, safe relationship. This is the foundation which parents and therapists must lay before healing can begin.
On their webpage dedicated to eliminating self-harm through education, the Mayo Clinic advises adolescent self-harmers that “expanding social networks” is a great way to help mitigate self-harm. Why is this? Because connection with other human beings is the primary way for adolescent girls who hurt themselves to reduce shame, feel valued, and fill time with healthy activities.
Other female adolescent clients of mine have found comfort in sharing their anxieties with a trusted friend. Having immediate access to their “self-harm Sponsor” at any time was a key to healing. Texting, Facebook, email, and cell phone calls make their friendships accessible and immediate. Additionally, the advent of social networking technologies, such as Twitter, make an entire group of healthy friends immediately accessible with a simple text message via cell phone.
Re-establish Identity and Worth
Often, there is deeper meaning to adolescent self-injury than what might be readily observable. One young woman wrote the following after her therapist asked her to define her deeper reasons for self harm. She calls them her “deeper issues.”

By deeper issues I meant that whoever is trying to help should deal with (or find someone who is qualified to deal with) the trauma/abuse, family issues, self-confidence issues, etc. Sort of like how when you’re helping someone with an eating disorder you don’t obsess about their weight, you figure out why they have developed an eating disorder and deal with those issues.

One example of “deeper meaning” can be tied to an identity crisis. Adolescents struggle anyway with knowing who they are, but this is an even more difficult dilemma for teens engaged in cutting. Self-injury for these adolescents isn’­t just a part of them, it is them; it defines their sense of self.
When a therapist or other caregiver helps a young woman reconnect with her identity, especially who she was as a child growing up, it can be a powerful entry point for effective therapy and can help correct the problem. Often, the pain with which she is trying to cope has blinded her to any positive events in her past. Scrapbooks, photographs, and stories about her can be touchstones she can return to when she forgets who she is or is confused by the turmoil that the immediate pain causes in her life.
Therapists and parents can seize upon quiet moments of reflection to take a “memory walk” with a struggling adolescent. Building on the foundation of an affirming relationship, she will be more likely to listen when we tell her what we think of her. If we tie our stories to concrete events, to things which she cannot deny have happened, it adds credibility to our opinion of her, and she will eventually return to a more complete memory of herself. I like to call it “re-memory.”
It’s not only identity which suffers when girls are in pain. The pain threatens the very idea of their self-worth. At her core, she begins to lose hope in the value she brings to the world and her family and friends. She loses touch with the infinite part of herself; the part which cannot be measured and which is invaluable.
Many months ago I led a group therapy session and brought a strand of my mother’s pearls with me. I pulled the milky-white chain out of my pocket and held it up to the ten young women seated in a circle near me. I explained that I had inherited the pearls after my mother died. My father had purchased them for her in Taiwan while he was stationed there during the Vietnam War. Furthermore, I said, I was going to give the pearls to my daughter when she turns 16. I added that I feel it is more than mere coincidence that my daughter’s birthstone happens to be “pearl”.
After allowing them each to hold the strand, I asked them what they thought the pearls were worth. “Are they real?” one asked.
“Yes. What do you imagine they are worth?”
“Do you mean how much they’re worth in dollars or in value to you?”
“In value to me.”
“You can’­t put a price on that!” one said. “You have to consider what they were worth to your father, too,” another said. “And to your daughter,” a third added. They all seemed to agree.
Having established the high value of the pearls, I tossed the strand on the wet and muddy floor. The girls were stunned. One stared at me as if I had gone out of my mind.
“What are they worth now?” I asked. “Have they lost any value?”
“No” was the quick reply.
I put my shoe on the pearls and rubbed the strand around on the dirty floor. This time the girls were angry. “What’s wrong with you?” one said. Her voice was loud. “Why are you doing that?” another said, and others echoed her question.
I ignored them. “Have the pearls lost any value now? They’re dirtier. And certainly my stepping on them has made them worth less. Treating pearls like this cheapens them, right?”
“You’re crazy!” one said.
“You don’t deserve those pearls!” said another. “What would your mother think?” Another said, “If I were your daughter, I’d be so pissed!”
Still I pressed them to answer my question about the value of the pearls. All agreed that the pearls had not lost their value. We discussed the similarity between the pearls and their own histories. Many felt downtrodden, dirty, and abused, like my pearls. Many, if not all, had lost sight of their intrinsic value.
Understanding spread across their faces as they applied the object lesson to their lives.
Similarly, treating self-harm requires us to see beyond the surface. We can never help a young woman heal if we don’­t acknowledge the true nature of the problem, as well as its scope. That said, it is important to remember that the problem may appear imposing and intractable, but it is critical that we communicate to her that, with help, nothing is impossible to overcome.
Emphasize Choice and Personal Power
As therapists and parents, we sometimes forget that our job is to influence adolescents in our care to make good decisions, not to manipulate, shame, or control them into more positive behavior. We become so anxious for the welfare of our clients and daughters, that we unthinkingly trade our respect for their individual agency for our need to reduce our own anxiety for their safety. At times like this, it’­s important to remember that the only control we have over any human being, including our own children, is the power of persuasion that exists within our relationship with her. Our relationships should be built on alliance, not compliance.
Authoritarian forms of relationship will eventually produce the opposite of what we want. Why do I state this so strongly? I’ll give the most simplistic example: when the young woman leaves our presence, our immediate influence ends. Once she’­s alone, she might think twice about hurting herself only if she has respect for someone else, wants to do the right thing, and cares that someone will be devastated if she hurts her body
The relationship is all we have.
JoAnna, a 14-year-old who carved words like “HATE” and “PIG” on the inside of her thighs said,
“I think one of the most important dynamics in a self mutilator’s treatment is to make sure they are aware that thoughts of cutting will linger for a long time, but refusing to act on those impulses is what matters most. As with most self destructive behavioral patterns, there are no means by which to end a person’­s harmful activities, short of locking them up in a padded room, etc. I strongly believe that only the conscious intent of a patient to cease whatever harmful activities they have engaged in will end abusive patterns to the self.
“Though honestly and openly seeking the true nature behind masochistic acts can aid in a person’s therapy, the ultimate responsibility for change towards emotional betterment rests squarely upon the shoulders of the patient – once they realize their actions no longer (if ever) serve a useful purpose. A decision coming from within to stop negative behavior, without external influences, is considerably more potent and therefore has a higher chance for success and perpetuation.”
It’s important to emphasize to young women that they have control of themselves. Especially in our society today, when so many young girls are taught to ignore their instincts, their inner-voice, girls need a trusted adult to validate their competence.
If we try to “fix” things for a young woman – to do more or work harder than she works, we inadvertently communicate that she is incapable. We reinforce what she desperately wants not to believe.
Every act, every word we utter must assert our confidence in her ability to heal her own pain. Drowning her distress and doubt, she must be brought back to the surface for a gulp of clean air; we must help her breathe in her own resourcefulness. In this way, she will never confuse her success with our help. She will view her success as she should- as her own.
Provide Options to Replace the Self-harm
What I am about to write next is something none of us like to hear.
In fact, one father disliked what I am about to write so much that he crossed the room, face beet-red and arms swinging wildly, shouting that I had just ruined a perfectly good group therapy session. What caused him to react so violently? It was this: She will harm herself again. It’­s not over. She will lapse back into the familiar, destructive behavior.
Knowing this, it is imperative that we provide other options for young women who are hurting themselves, yet have expressed a desire to stop. New habits and new coping skills provide a line of defense against self-injury, especially when the girl is feeling lonely. One former client, Melissa, said:

“I know it helped me to learn other coping mechanisms and use them. Find other ways to get out your feelings, a way that works for you. Some people like talking. Some like music or art, journaling, etc. You have to find what works for you. And a lot of times it doesn’­t feel as good as cutting, which may seem like the best quick fix, but if you get through to the person that in the long run it makes problems worse, then getting through it in a different way is more acceptable.”

Another client cautioned me, in a darkly humorous way, that some options are more effective than others:

“Things not to do: in one of the psych hospitals I was in they told me to put a rubber band around my wrist and snap it whenever I felt like cutting. Not helpful, but a good way to get a black-and-blue wrist. Another psych hospital had me draw over all my scars in red pen when I felt like cutting. Not helpful, and it made me wonder if maybe they should be the ones in the psych ward!”

Here is a long list of options for replacing self-harm, some of which I’ve found to be better than others:

  • Deep breathing
  • Relaxation techniques
  • Call a friend, your therapist or a crisis line
  • Try not be alone (visit a friend, go shopping, etc.)
  • Take a hot bath
  • Listen to music
  • Go for a walk
  • Write in a journal
  • Punch a bed or a pillow (when nothing but a physical outlet for your anger and frustration will work)
  • Hold ice in your hand (I don’t like this option, but some people say it works)
  • Avoid temptation (i.e., shave legs less or only around others, etc.)
  • Try to find your own creative ways as outlets for emotions
  • Learn to confront others respectfully/make your own feelings known instead of keeping them inside
  • Go outside and scream and yell
  • Take up a sport (a form of exercise can help you release tension)
  • Work with paint, clay, play-dough, etc. (The person who suggested this mentioned that she would make a big sculpture and then do whatever she wanted to it. She said it was helpful to calm the urge to self-injure, plus it gave others clues to what might be going on)
  • Draw a picture of what or who is making you angry
  • Instead of harming yourself, try massaging the area you want to harm with oils or creams, reminding yourself that you are special and you deserve to treat yourself and your body with love and respect
  • Go to church or your place of worship
  • Wear a bracelet or something that will fit on the places that you injure. One person did this as a way to remind herself that she could call someone instead of hurting herself and that she had other ways to cope
  • Break the object that you use to self-injure as a way to show that you have control over it
  • Write the phone number of a friend on your wrist
  • Write a letter to the person(s) that have hurt you and express how he/she/they made you feel. These letters do not have to be in perfect form and you do not have to please anyone but yourself. You do not have to give these letters to the people, but it is a great way to release the feelings that you are carrying. After you write the letters, you can decide then what to do with them. Some people find destroying the letters helpful (i.e., tear them up, throw them in a lake, burn them, etc.)
  • Do some household chores
  • Cook
  • Try some sewing, cross stitch, etc.
  • Use the object you typically use to self-harm in the way it is meant to be used
  • Recite a poem or prayer that comforts you
  • Write down all your positive points and why you do not deserve to be hurt
  • Write in your journal why you want to hurt yourself. If you have hurt yourself, write down what caused it to happen so in the future you can prevent it from happening
  • Play some kind of musical instrument. Even if you don’t really know how to play, picking out tunes is a way to concentrate and help get rid of the urge to harm yourself
  • Yoga
  • Allow yourself to cry. Getting the tears out can make you feel better
  • Take a shower
  • Sing a song about what you are feeling. You can even make one up
  • Scribble on paper. Clutch the pen in your fist. It’s a way to diffuse it on to paper. (Get a few sheets so that they don’t tear)
  • Make a list of reasons why you are going to stop cutting. Carry it in your pocket or tape it to the bathroom mirror. Every time you get the urge, read the list to remind yourself why you shouldn’t

So, we have established a physical environment that is safe. We have a healthy, affirming relationship with the adolescent. She trusts us enough to show her therapist and/or parents her scars and tell us how, when, and why she cuts. She explores the deeper issues that plague her. She is able to see value in her life. She expresses a desire to change and has proven, through a series of recent choices, that she means to follow through on her newfound commitment to life. And we’ve provided her with a slew of new options that work for her.
Success is right around the corner!