Defining the ProblemSelf-injury (SI) is much more common than oncebelieved. An estimated 1% of teens self-injure at sometime, and 90% of those are girls. Teens self-injure formany reasons; most say it is a way to control their feel-ings when they are having unacceptable thoughts anddisturbing feelings, such as shame or guilt. These feel-ings typically relate to earlier events in their lives; anestimated 50% have had a significant trauma duringchildhood. Many teens report that their self-injuriousbehavior helps them disassociate from their disturbing feelings. But while SI seems to temporarilyalleviate those feelings, the behavior itself causes distressful feelings. New feelings of isolationand loss of control result, leading to more self-injury. Breaking this cycle is an important part of thetreatment for these teens.The act of self-injury can take many forms, from cutting and burning to picking at scabs or pullingout hair. Most teens do not want to permanently injure themselves; they participate in what somecall “gentle scarring.” However, some teens cause serious and permanent tissue damage by theirself-injury. Most commonly, teens injure themselves in places on their bodies that are usually

This Instant Help Chart was written byLawrence Shapiro, PhD

This is a complex and very important question.Most teens who self-injure do not need to behospitalized. Generally their wounds are super-ficial and require only minimal medical treat-ment. Often when parents discover that theirteens are injuring themselves, they are soupset that they immediately try to get them hos-pitalized, but this can have an adverse effect.Teens typically say that they hurt themselves togain a feeling of control, and hospitalizing themagainst their will makes them feel even morepowerless. On the other hand, hospitalizationcan provide the structure and support neededfor teens to make significant changes in theirlives, providing that the hospital has a well-thought-out program tailored to the needs ofteens who self-injure. This type of program isdiscussed in Bodily Harm, by Karen Conteiroand Wendy Lader (Hyperion Books, 1998).

Books for ParentsBodily Harm. Karen Conterio and WendyLader, Hyperion Books, 1998The Scarred Soul; Understanding & EndingSelf-Inflicted Violence. Tracy Alderman,New Harbinger Publications, 1997When Your Child Is Cutting.Merry McVey-Noble, New HarbingerPublications, available July 2006Books for TeensStopping the Pain: A Workbook for TeensWho Self-Injure. Lawrence Shapiro, InstantHelp Books, 2006Books for ProfessionalsTreating Self-Injury: A Practical Guide.Barent Walsh, Guilford Press, 2005See My Pain: Strategies and Activities forYouth Who Self-Injure. Susan Bowman andKaye Randall, Youthlight, Inc., 2004

Recommended Websiteswww.selfinjury.com This is the website ofSafe Alternatives, one of the country’s bestknown programs for treating SI. It includes anational list of therapists who specialize intreating SI.www.nmha.org This is the website for theNational Mental Health Association and is agood source for facts on self-injury andrelated disorders.

Should Teens WhoSelf-Injure Be Hospitalized?

Instant Help forTeens Who Self-Injure

Instant Help forTeens Who Self-Injure

This chart is intended to provide asummary of the critical informationavailable on helping teens whoself-injure to insure that everyteen gets the most appropriateand comprehensive consideration.

Assessment should begin with a seriesof interviews. Since most teens areashamed of their self-injury, it may takeawhile for them to trust the clinicianenough to reveal the extent of theirself-injury habit, much less the underly-ing causes. More formal assessmentsmight include:

Trauma-Related Guilt Inventory(TRGI), Western PsychologicalServices

The Endler Multidimensional AnxietyScales (EMAS), WesternPsychological Services

The Suicide Probability Scale(SPS), Western PsychologicalServices

Beck Depression Inventory,(Psychological Corporation)

Projective tests and broader personalitytests might also be appropriate. A func-tional behavioral analysis would beuseful in breaking the habit of usingself-injury to cope with stress.

Assessing Teens Who Self-Injure

About Instant Help Charts

Counseling Teens WhoSelf-InjureTeens who self-injure benefit from a variety oftreatment interventions, and therapy will typi-cally last from two to five years. Along withpsychodynamic and supportive therapy, thefollowing treatments are recommended:

Cognitive Behavioral Therapy can helpchange the dysfunctional thoughts that canlead to self-injury.

Journaling can provide insight into thefeelings that cause teens to self-injure, aswell as help control the impulse to self-injure.

Group Therapy can help teens develop anetwork of people to turn to when they aredistressed.

Mindfulness is a type of meditation thaturges people to be aware of their thoughts,

While teens will have different therapeuticgoals depending on their backgrounds andlife circumstances, the primary objective forall is to stop the self-injury. The followingtreatment goals can help accomplish thisobjective: To help the teen create a window of time

between the impulse to hurt and theactual injury

To help the teen develop a support net-work for times of emotional crisis

To help the teen develop behaviors thatcan be a healthy substitute for self-injury

To help the teen change the dysfunc-tional thoughts that lead to self-injury

To help the teen learn to deal with dis-tressing feelings that lead to self-injury

To help the teen develop a better bodyimage

To help the teen develop an emergencyplan to follow when she has the impulseto self-injure

To help the teen understand feelings orsituations that trigger her self-injury

To help the teen give up the rituals thataccompany her self-injury

To help the teen deal with the shame orguilt associated with self-injury

To help the teen find ways to feel in con-trol of her life

To help the teen find more pleasure andhappiness in her day-to-day life

Self-injury is considered asymptom or behavioralexpression of underlyingdisorders that oftenrespond well to medica-

tion. Most commonly, teens who self-injure are given medication fordepression or anxiety. SelectiveSerotonin Reuptake Inhibitors (SSRIs)are the most commonly prescribedmedications for depression and arefrequently used to treat anxiety disor-ders as well; brand names includeProzac, Lexapro, Zoloft, andWellbutrin. Other anti-anxiety medica-tions include benzodiazepines, suchas Ativan, and azaspirones, such asBuSpar. It is important to note that theFDA has warned that antidepressantmedication can actually trigger suici-dal thoughts in teens, particularly inthe first few months of use. Othermedications, including antipsychotics,can also be useful, but care must betaken for adverse side effects andpotentially adverse drug interactions.

(continued on p. 2)

4 • Instant Help for Teens Who Self-Injure

(continued on p. 2)

Resources for Helping Teens Who Self-InjureMedication andSelf-Injury

CAUTIONThere are many websites andblogs run by teens and adultswho self-injure. While most ofthese are well intentioned, theymay contain graphic descrip-tions and personal historiesthat might actually contributeto a teen’s hurting herself.

Goals in Developing a Treatment Plan

Researchersbelieve that theneurotransmit-

ter system, andin particular the cells

that affect the production anduse of serotonin, may predisposesome people to self-injury by makingthem more aggressive and impulsive.Many teens who self-injure haveexperienced trauma in their childhood,which may also affect the hippocam-pus, a part of the limbic system whereemotional memories are stored. Theaddictive quality of self-injurysuggests that abnormalities in the

brain’s production of dopamine, theneurotransmitter responsible for thesensation of pleasure, may contributeto a predisposition to self-injury, aswell as other compulsive behaviors. Itis also believed that the endocrinesystem, which includes the hypothala-mus and the pituitary and adrenalglands, plays a role in self-injury. It iscommonly believed that the act ofself-injury causes the brain to releaseendorphins, which both diminishes thesensation of pain and produces atemporary “high.” Some people theo-rize that people who self-injure alsohave a naturally high pain threshold.

The Brain and Self-Injury

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A Brand of The Guidance Group1.800.962.1141www.guidance-group.com

Finding out that your teen intentionally hurts herself is always a shock. Many parents areflooded with feelings of shame and guilt and don’t want others to find out that their teen hasproblems. The best thing you can do for your teen is to learn about this problem and to consulta trained counselor or family therapist.Teens almost always keep their SI a secret as long as they possibly can. But when you findout about a teen’s self-injury, you must learn to talk about it directly and compassionately.Ignoring the problem or hoping that it will go away never helps.It is important to recognize that you cannot force your teen to stop injuring herself. Punishment, nagging, or any kind of coercion will likelyworsen the behavior. Instead, you should support your teen by motivating her to stop her SI. Here are some ways you can do that:

Encourage her to create a healthy lifestyle.

Help her learn to cope with family stress.

Show you care by taking time each day to talk with her about her concerns in a nonjudgmental fashion.

Reflect her feelings.

Encourage her interest in relaxation activities, like yoga or meditation.

Let her know that you want to help her deal with the problems that led her to self-injure.

Be a good role model for dealing with problems.

Many parents benefit from self-help groups that provide support from parents of other teens who self-injure. Check with your school coun-selor or local hospital to see if they know of such groups in your area.

DON’T

• Avoid talking to teens about SI.

• Rush teens to a hospital unless a wound islife threatening.

• Tell teens to keep their SI a secret.

• Ignore the reasons behind the teen’s self-injury.

• Assume you can stop teens from hurtingthemselves.

• Expect that self-injury will resolve quickly.

DO

• Learn to talk about SI as a problem you can acceptand help with.

• Make sure there is a careful evaluation of the teen’smental status and a thorough treatment plan.

• Help teens understand and cope with all theirdifficult feelings.

• Seek treatment for the underlying emotional problemsthat accompany SI, as well as comorbid disorders likedepression and eating disorders.

• Accept SI as an addictive behavior and help find waysto motivate the teen to stop.

• Seek long-term help for the teen.

2 • Instant Help for Teens Who Self-Injure

Some teens treat self-injury as a casual behavior, like getting a tattoo, but when teens repeatedlyhurt themselves, it is always a sign of emotional trouble. As a teacher, you are likely to be the firstadult to become aware of a teen’s self-injury, and you must immediately share your concern withyour school support staff (nurse, counselor, or school psychologist) or your school administrators.You may not think there are teens in your school who self-injure, but statistics say that there is atleast one teen who hurts herself for every 100 students in any school. When school staff is unawareof this problem, it is probably because teens are very good at hiding it. Some warning signs of self-injury include frequent unexplained injuries, including cuts and burns; pants and long sleeves worn inwarm weather; low self-esteem; difficulty in handling feelings; relationship problems; and a drop in grades and school attendance.Awareness of self-injury should be part of a school preventative mental health plan along with drug and alcohol awareness campaigns. Teensshould regularly be given information about self-injury, depression, and eating disorders, and they should have the opportunity to discuss howthey can help other students with these problems.In addition, school staff should be trained on how to respond to students who self-injure, including: How to recognize the various forms of self-injury How to respond in a dispassionate but concerned way Distinguishing self-injury from suicide attempts Whom to contact about a student's self-injury How to handle rumors or gossip about a student's self-injury How to recognize when a student needs immediate medical or psychiatric attention

Instant Help for Teens Who Self-Injure • 3

All teens who self-injure will benefitfrom Replacement Skills Training,whose aim is to find a substitute behav-ior for the self-injury. Replacementbehaviors can include: Physical exercise Writing Art Diversions (using a computer,

watching a movie) Playing or listening to music Talking to othersSome therapists also prescribeNegative Replacement Training, whichis intended mimic SI in a benign way.For example, Marking one's body with a red-col-

ored marker Snapping a rubber band on the arm Putting ice packs or ice on the skin Putting an ointment on the area of

the skin where SI usually occursThis technique is controversial becausethese replacements can turn into self-injury or trigger self-injury in someteens. However it is worth noting thatsome teens find these helpful as atransition from SI.

Replacement Skills Training The Dos and Don’ts of CommunicatingDefining the Problem (continued)

covered by clothes, including arms, legs,stomach, and chest. Many follow some sort ofritualistic behavior, inflicting their wounds inthe same way, in the same physical environ-ment, and even at the same time of day. Adultintervention in the behavioral pattern thatprecedes self-injury can be very helpful.It is common for teens who self-injure to alsohave eating disorders or other serious emo-tional problems, including depression andanxiety disorders. The most serious kinds ofSI are associated with personality disorders,including borderline personality disorder. Manyteens disassociate from their behavior, report-ing that it is as if they were watching someoneelse do the behavior and that they don’t feelthe physical pain.There is no question that the sooner SI isdetected, the more easily it can be treated.But self-injury is almost always done insecret, and it can continue for months, evenyears, without adults being aware of it.Parents’ denial of the seriousness of thisbehavior can also delay teens’ obtainingcomprehensive treatment.

What Parents Need to Know

What Teachers Need to Know

feelings, and sensations, even for just ashort period each day. Mindfulness trainingmay help teens break the habit of disasso-ciation.

Behavioral and EnvironmentalInterventions help teens change the cuesand situations that trigger their self-injury.

Coping Skills and Emotional RegulationTraining teaches teens better ways tocope with external stress, as wellemotional distress.

Family Therapy focuses on ways thatfamily members can help the teen whoself-injures.

Inpatient or Outpatient Hospitalizationmay provide a structured environment forteens who are extremely depressed orwhose behaviors seem beyond theircontrol. (See p. 4, “Should Teens WhoSelf-Injure Be Hospitalized?”)

By definition, SI is not considered to be a suicide attempt.In fact, some psychologists believe that self-injury can be away for teens to avoid overwhelming thoughts and feelingsthat could lead to suicide.

Teens who self-injure say that they are not hurting them-selves in an attempt to cause death, but rather to calmthemselves and escape from their troubling thoughts and

feelings. However, self-injury can be associated with otherdisorders, including depression and borderline personalitydisorder, where suicidal thoughts and attempts are com-mon. According to the National Mental Health Association,more than 5,000 young people between the ages of 15 and24 kill themselves each year, nearly triple the rate in 1960,making the possibility of suicide a concern for all seriouslytroubled adolescents.

Are Teens Who Self-Injure Suicidal?

Counseling Teens WhoSelf-Injure (continued)

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