Liesje Donkin, Clinical psychologist
First and foremost, be non-judgemental. It's often difficult for young people to talk about their DSH, particularly when people haven't reacted well to it previously.
Deliberate self-harm (DSH) is an issue that tends to divide clinicians, consumers and parents alike. Many people cannot understand what would drive someone to deliberately hurt themselves regardless of how much pain they are feeling. I mean, creating pain to manage pain seems stupid right? So the purpose of it must be attention seeking?
Why do young people self-harm?
Labelling DSH as attention seeking is invalidating and potentially dangerous. Whilst some people who DSH may do so to communicate their distress, they can also do it for a number of other reasons. These reasons include to help them feel when they are emotionally numb; to distract themselves from the pain they are experiencing emotionally; to regulate themselves emotionally; to punish themselves; or to disfigure themselves. Importantly, DSH is not intended as a way to end their lives1. However, there is an increased risk of suicide in those people that do DSH2 with the risk of suicide increasing with episodes of DSH3. For these reasons, DSH carries very real risk and should not be considered as attention seeking.
What should I do if a young person discloses self-harm?
First and foremost, be non-judgemental. It's often difficult for young people to talk about their DSH, particularly when people haven't reacted well to it previously. Many are also concerned that their parents or loved ones might get told. Covering confidentiality is therefore important to ensure the continuity of the therapeutic relationship so that the young person can continue to feel comfortable working with you.
Checking safety is also key. If the conversation occurs in each session it can help the young person feel more comfortable with discussing DSH and suicidal ideation. It becomes the norm and gives them the opportunity to discuss it without having to raise it. Creating such a space in each session can build trust and can be aided by the use of diaries or apps to record the behaviour.
Finally, it's important to consider how to treat DSH in session. It can be useful to work with the client to place some hurdles to DSH. This might include removing objects from the location which the young person engages in DSH or reducing the time they spend in isolation. Determining the function of the DSH is also useful so that an alternative behaviour can be substituted for it4,5. For example, if the behaviour provides a physical distraction then high intensity exercise may work as a substitute. Alternatively, squeezing ice or biting down on a lemon may work. Whilst these behaviours work for some young people, they might not work for all. Given this, it's important to work with the young person to develop a list of alternative behaviours that they can use to distract themselves from their DSH urges so that they can build their confidence in coping without it. Finally, ensuring that a safety plan is in place to help the young person through their difficult time is an important part of any management plan.
- Skegg, K., Self-harm. Lancet, 2005. 366(9495): p. 1471-83.
- Hawton, K., D. Zahl, and R. Weatherall, Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. The British journal of psychiatry : the journal of mental science, 2003. 182: p. 537-42.
- Zahl, D.L. and K. Hawton, Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11,583 patients. The British journal of psychiatry : the journal of mental science, 2004. 185: p. 70-5.
- Muehlenkamp, J.J., Empirically supported treatments and general therapy guidelines for non-suicidal self-injury. Journal of Mental Health Counseling, 2006. 28(2): p. 166-185.
- Klonsky, E.D. and C.R. Glenn, Resisting Urges to Self-Injure. Behavioural and Cognitive Psychotherapy, 2008. 36(2): p. 211-220.