Self-harm: what it really means and how to respond

It is June, thirty degrees, and for three weeks your daughter has been wearing a long-sleeved jumper. Then at lunch her sleeve slips up to the elbow and you see thin, parallel lines on the inside of her forearm. Some are fresh, others already white. She notices you looking, pulls the sleeve back down and says, “The cat scratched me.” You don’t have a cat.

Parents who describe a moment like this to me remember it physically — like a punch in the stomach. What follows is a wave of contradictory thoughts: horror that your child wants to die; anger that they did this to themselves; shame that you didn’t notice sooner; and fear that one wrong word will make everything worse. This post is meant above all for you as a parent who has arrived at this point. I will try to explain what self-harm most often means, what it does not mean, how to respond in the first conversation, and where to find help.

Before I go on: if there is any suspicion that your child is in immediate danger or has seriously injured themselves, call 112. In Slovenia young people can call the TOM helpline on 116 111 at any time, and for suicidal thoughts there is the Klic v duševni stiski crisis line on 01 520 99 00 (7 pm to 7 am) and the Samaritans line on 116 123 (24 hours).

What self-harm is

In the professional literature, what I am talking about is called non-suicidal self-injury: deliberately injuring one’s own body without the intention of dying. Most often it involves cutting, scratching, hitting, burning or interfering with wound healing. But it can also be less visible — banging one’s head against a wall, biting, scratching until it bleeds in places nobody sees. You will find a shorter explanation of self-harm in the knowledge base.

The important word is non-suicidal. Most young people who self-harm don’t do it in order to die. They are doing something else — something that makes sense to them in that moment. What that is, is the central question of this post. But it does not mean suicidality can be ruled out; I will come back to that.

How common it is

Parents often think their child is the only one. They are not. A systematic review and meta-analysis of studies in general, non-clinical populations (Swannell et al., 2014) found that about 17 per cent of adolescents had self-harmed at least once in their lives. The proportion was lower among young adults and lower still among adults. Self-harm most often begins in early adolescence.

This figure does not mean self-harm is “normal” and no cause for concern. It does mean it is not a sign that your child is “mad”, or that your family has got something terribly wrong. It is a relatively common, but serious, way in which young people cope with distress they cannot carry in any other way.

Why: what self-harm does

The researchers Matthew Nock and Mitchell Prinstein proposed that we understand self-harm by what it gives a person. A later review of the evidence by David Klonsky showed that by far the most common function is regulating unbearable emotions. Young people describe tension, anger, anxiety or emptiness rising until it becomes unbearable — and after self-harming comes a short-lived relief.

Alongside this, other functions often appear:

• To feel something. When a person is cut off from themselves, numb, as if watching their own life through glass, pain gives back the sense of being real. We call this state dissociation.
• To punish oneself. Young people who carry a lot of shame sometimes say they “deserved it”. I have described how this emotion works in Shame: the emotion that whispers “There is something wrong with me”.
• To speak without words. Sometimes a wound is a message a person cannot put into words: “I’m in pain.” That is not manipulation — it is the language available when there is no other.
• To redirect pain. Physical pain is tangible; it has a beginning and an end. Emotional pain often doesn’t.

Attention-seeking? Why this explanation does harm

The most common reaction from those around — sometimes even from health professionals — is: “She’s only doing it for attention.” This sentence is almost always wrong and almost always harmful.

It is wrong because most young people hide their wounds. If it were about attention, they would show them. And it is harmful because even when part of self-harm is a message to others, that message is not “look at me” but “I can’t cope”. A person who has to reach for such an extreme language to be heard needs more attention, not less.

A second myth is that this is a problem for girls. Research does show that self-harm is more often identified in girls, but boys self-harm too — more often by punching walls or objects, which those around them prefer to read as “anger” rather than self-harm. A third myth is that it is a “fad” that will pass on its own. For some it does pass; for others, without help, it hardens into a pattern that lasts for years.

Does it mean they want to die?

Most often, no. But this question should not be dismissed too quickly. Research shows that self-harm — even though its purpose is different — is one of the important risk factors for a later suicide attempt. Someone who has grown used to tolerating pain and the fear of injuring themselves has a lower threshold for one day doing something more dangerous.

That is why it is right to ask your child directly: “Do you ever think you would rather be dead?” Many parents fear that such a question would plant the idea. A review of the research (Dazzi et al., 2014) found no evidence that asking about suicide increases suicidal thoughts; some young people even reported relief after such a conversation. I have written more about what a conversation about suicidal thoughts sounds like in When you think it would be better if you weren’t here: on suicidal thoughts.

If your child says they are thinking about suicide, have a plan or have already tried something, don’t stay alone with it. Contact your GP, paediatrician or the out-of-hours service the same day; in immediate danger call 112.

The first conversation: how to begin

The American self-harm specialist Barent Walsh recommends a stance he calls respectful curiosity: a calm, low-key tone, interest in what is going on, without excessive alarm and without judgement. You don’t have to be completely calm — it is enough that your child doesn’t get the sense that, on top of everything, they now have to calm you down as well.

It might sound like this (a composite, not a real person):

Dad: “Nina, I saw your arm. I’m not going to be angry. I’d just like to understand what is going on for you.”
Nina: “Nothing’s going on. Don’t make a drama out of it.”
Dad: “All right. I won’t make you tell me everything now. There’s just one thing I’d like to know: is it ever so bad that you’d rather not be alive?”
Nina (after a long silence): “No. Not like that. It’s just … sometimes it’s too much. Then it’s better.”
Dad: “Thank you for telling me that. I don’t know yet how to help you, but you won’t be alone with this.”

The father in this conversation doesn’t find out everything. He doesn’t get a promise that it won’t happen again. But he achieves something more important: Nina learns that the secret can be spoken without the world collapsing. It is precisely the secrecy that keeps the cycle of self-harm going.

I have described how to talk with a teenager about mental health in general, before there is a crisis, in How to talk to your teenager about mental health.

What to avoid — and what helps

In the first hours and days, parents often do things that come from love and panic but push the child away. A few come up again and again:

• Demanding a promise. “Promise me you’ll never do it again.” Your child will promise, because they want the conversation to end. The next time they self-harm, they will carry, on top of the distress, the feeling that they have broken a promise — and they will hide the wounds even better.
• Punishment. Taking away the phone or banning going out as a punishment for self-harm says that the problem is the behaviour, not the pain.
• Constant checks. The urge to check their arms is understandable, but checking every evening turns the relationship into surveillance and deepens the shame.
• Silence. Some parents fear that talking will make things worse, so they say nothing. A child often understands this as “you can’t bear it either”.

What helps is simpler, but harder: take care of the wounds (clean dressing, and a doctor for anything deeper), remove or lock away medicines and any sharp objects that aren’t needed, without making a show of it, stay available, and find professional help. And look after yourself: a parent also needs someone with whom to work through the horror, guilt and anger that this moment has brought.

Guilt is almost unavoidable for parents. “Where did I go wrong?” is a question I always hear. The family environment plays a part — but self-harm also appears in families where parents are caring and present. The causes are often intertwined: temperament, peer relationships, school, experiences parents don’t know about, and the sensitivity of the nervous system. Guilt that paralyses you does not help your child. Responsibility that moves you to act does.

Exercise: preparing for the conversation before you start it

If you have discovered or suspect self-harm but the conversation hasn’t happened yet, take half an hour for yourself before you begin. This exercise helps you not to go into it at peak alarm.

1. Write down what you feel. Fear, anger, guilt, shame, disgust, sadness — whatever is there. These feelings are not wrong, but they are yours, and it is right to recognise them before you sit down with your child.
2. Calm your body. A few minutes of slow breathing with a longer out-breath, or a walk round the block. Your child will read your face and tone more than your words. Why this matters is described in the entry on the window of tolerance.
3. Write down your first sentence. Short, descriptive, without a “why” question: “I saw your arm. I’d like to understand how you are.”
4. Choose a time and place. Not in front of siblings, not just before school, not in the middle of a row. It is often easier during a shared activity, in the car, on a walk — where you don’t have to look each other in the eye.
5. Decide on one next step. Not everything at once. It might be a visit to the doctor, or an agreement that she will tell you when things get bad again. Say it at the end of the conversation, and keep to it.

What kind of help works

The first door is the GP or paediatrician, who will treat any wounds, assess the risk and refer on — to a child psychiatrist, a clinical psychologist, or a mental health centre for children and adolescents where one is available. The school counselling service matters too. I have described when and how to bring a teenager to a therapist in When to take a teenager to a therapist: signs, routes and what if they refuse.

For adolescents who self-harm repeatedly, the strongest evidence is for dialectical behaviour therapy adapted for adolescents. In a randomised trial in Norway (Mehlum et al., 2014) this approach reduced self-harm more than usual care did. It matters that parents take part in this form of therapy too: the adolescent learns to recognise and tolerate emotions — what the entry on emotion regulation describes — and the parents learn how to support them in this.

Alongside individual help for the teenager, family therapy can also be useful. Not as a replacement, but as a complement: it helps open up conversations in the family that have long been closed, and means parents aren’t left alone with everything they have discovered. I have described how this works when a teenager stops speaking at home altogether in When a teenager goes quiet: how family therapy opens the conversation.

Many parents worry about whether they will find out what their child tells the therapist. With adolescents, the rules of confidentiality depend on age and circumstances, and in the case of serious danger a therapist will always break it. I have described where the limits lie in Confidentiality in therapy: what stays between us and where the limits are. Privacy with a therapist is often exactly what makes it possible for a teenager to speak.

Where this explanation falls short

I want to be honest about the limits of what I have written.

Not all self-harm is “just” emotion regulation. Sometimes it is part of depression or an eating disorder, or the consequence of trauma or abuse that is still going on. If so, calm conversations at home are not enough — a thorough assessment by a professional is needed. I have described how to recognise depression in young people in Teenage depression: telling it apart from ordinary mood swings.

A parent’s calm is not a cure. Respectful curiosity opens the conversation, but it does not remove the causes. A parent who has learned the right sentences may still be powerless in the face of distress that is bigger than the family. That is not their fault.

It is not always about the family. For many teenagers the trigger lies outside the home — bullying, loneliness, an experience they cannot talk about. Looking for the cause within the family can even divert attention from what is really happening.

And a crisis is not the moment for reflection. Everything I have written about the conversation applies when there is no immediate danger. When there is, the difference between a crisis response and a therapeutic process is crucial — more on this in First aid is not therapy: crisis support and the therapeutic process.

What to remember

• Self-harm is most often a way of surviving unbearable emotions, not a suicide attempt and not attention-seeking.
• It is relatively common — a meta-analysis found that about 17 per cent of adolescents had self-harmed at least once.
• Still, always ask about suicidal thoughts. The question doesn’t plant the idea; in danger, call 112.
• Don’t demand a promise and don’t punish. The aim of the first conversation is for the secret to become sayable.
• Find help for your child and for yourself — a doctor, the school counselling service, therapy for adolescents and, where needed, family therapy.