It is a sad reality that some children and adolescents engage in self-injury. There are many ways that young people do this. Currently, on my caseload, I have young people, almost all in their teens, who cut, burn, or rub their skin raw with erasers. Some self-injure in ways that make it less obvious that the goal is to hurt themselves. I am seeing a teen who won’t drink when she’s thirsty and another who ties his shoe laces so tight that they cause pain and blisters on top of his feet. Some young people are very open about this behavior while others work hard to keep it secret. The majority of children and adolescents who self-injure want very much to stop but have not been able to find effective ways to deal with the emotional upset that leads to the behavior. Recently, a client of mine commented
I hate that I do it (cutting) and I want to stop, but when I go to that dark place, nothing else seems to bring me out of it. – Kyle, age 14
Self-injury is a behavior that must be taken seriously, one that requires professional intervention by clinicians who have expertise in this particular symptom. Self-injury is distinct from suicidality in that the goal is not to end one’s own life; the goal is to cope with emotional pain. For this reason, the term non-suicidal self-injury (NSSI) is often used.
NSSI is a symptom that spans many different diagnostic categories. Some young people who engage in this behavior are suffering from mood and/or anxiety disorders; some seem fine most of the time, but when something upsetting happens, they have big emotional reactions. Some young people with eating disorders engage in behaviors that fall into the broad category of NSSI. All children and adolescents who self-injure have one thing in common: poor coping skills.
I have written before about the fact that, in parenting dilemmas, safety must take precedence over everything else (see Safety, Relationship, Everything Else). If, as a parent, you ever have concern that your child is unsafe, then trust your instincts. If there is a mental health professional already involved in your child’s care, consult that individual. If not, contact your child’s pediatrician for advice or take your child to the emergency room. Assessing risk can be difficult for a clinician who is trained to conduct a thorough and objective evaluation; it is unwise for parents, who are neither trained nor objective, to be the ones to determine risk.
Any child or adolescent who is engaging in NSSI should be under the care of clinicians with expertise in dealing with this behavior. Usually, this means a therapist (social worker or psychologist) and/or a child-trained psychiatrist. Ideally, the therapist will be trained in a specific type of psychotherapy that has been shown, through rigorous research, to be effective in decreasing NSSI as well as some of the other problematic behaviors that often accompany self-injury. This therapy is called Dialectical Behavior Therapy (DBT). DBT is an outgrowth of the more familiar cognitive-behavioral therapy (CBT). DBT is heavily focused on teaching skills that improve coping and therefore reduce the risk of NSSI. In broad terms, the four sets of skills taught in DBT are mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Ideally, DBT includes both individual and group sessions as well as training for parents on how to respond to the challenging behaviors their children exhibit.
At some points in time, it is possible that a child or adolescent who engages in NSSI will be referred for a higher level of care than outpatient psychotherapy. There are three additional levels of care: intensive outpatient program (IOP), partial hospitalization (PHP), and inpatient hospitalization (IPH). While every program has unique features and schedules, here are general descriptions of each level:
- IOP usually meets 3-4 times per week for 2-4 hours and largely consists of group therapies. The length of participation varies widely, from a couple to several weeks. These programs often meet in the evening to minimize the disruption to the young person’s education.
- PHP typically follows a school schedule, that is, 5 days per week for 6-8 hours per day. In a PHP, a wide range of services is usually offered including individual therapy, group therapies, tutoring to help kids keep up with schoolwork, psychiatric evaluation and medication management as well as adjunctive therapies such as art, movement, music, and psychodrama. The length of stay in a PHP is usually around 2-4 weeks.
- IPH is very similar to PHP in terms of the program offerings, but IPH involves overnight stays. This level of care is typically reserved for individuals for whom safety is a significant risk. The lengths of stay tend to be short, almost always less than 2 weeks, and usually end with a transfer to PHP or IOP once the young person is no longer considered to be at risk.
Sometimes, the recommendation for a higher level of care will be made in a thoughtful way, in collaboration with the young person and parents. Other times, in a crisis situation, the outpatient clinician will send the young client to a hospital or psychiatric facility for an emergency evaluation where the appropriate level of care will be determined.
If you have a child who self-injures and is in ongoing outpatient therapy, you should expect to see a decrease in the frequency and intensity of NSSI over time. Progress will never be linear; there will be unexpected setbacks. If you are not seeing a general trend of improvement, then it would be wise to speak with the treating professionals (with your child’s consent, of course) to make sure you are clear about the type of therapy they are using, what barriers are getting in the way of progress, and whether a higher level of care or a different therapeutic approach might be warranted.
The following books may be of interest if you have a child who self-injures:
- Parenting a Child Who Has Intense Emotions: Dialectical Behavior Therapy Skills to Help Your Child Regulate Emotional Outbursts and Aggressive Behaviors by Harvey and Penzo
- Helping Teens Who Cut: Understanding and Ending Self-Injury by Hollander
While NSSI is a serious behavior that creates a lot of distress and alarm for parents, there is excellent evidence-based help available. If you have a child who self-injures, the challenge is to find the right type of professional help and then to provide the right types of support at home. I often recommend that parents who are dealing with a self-injurious child consider getting their own therapy. One of the most difficult but essential components of helping children who are in such despair that they hurt themselves is maintaining hope, but with the right types of help, there is every reason to be hopeful.
[Names and potentially identifying information have been changed to protect privacy.]