Vicki L. Loyer, Ph.D., LMFT
First published in the Desert Leaf February 2016
Wearing blue jeans, a white T-shirt, and Toms shoes, the tall, lean teenager sat politely. She engaged in conversation readily. Her hair hung straight; bangs covered her right eye. Occasionally, she would run her fingers through her bangs. Her fingernails were multicolor. On her arms she sported bangles of every type: each bracelet crafted with care—friendship bracelets, hair ties, and other assorted jewelry. Her parents said they couldn’t say specifically what, but something was not right with their child. They were worried. I asked the teen how long she had been cutting. She said, “two years.” Her parents were stunned. How did I know when I had just met her?
Unfortunately, it is not unusual to see the signs of self-injury when you work with enough teenagers. The common signs of self-injury include unexplained scars or marks, inappropriate dress for the temperature (sweatshirts in the summer), an unwillingness to participate in events that require less clothing (e.g., not dressing out for gym class), wearing many wrist bands, irritability, social withdrawal, and expressions of self-loathing or worthlessness.
“Normal adolescence” is an oxymoron. While some people go through adolescence fairly easily, others experience a time of storm and strife. Developmentally, adolescents experience two competing dilemmas: a personal fable (“I am so unique no one can understand me.”) and an imaginary audience (“Everyone notices everything about me.”). That is a lot to manage. Adolescence is a dangerous time for completed suicides, but cutting is often non-suicidal self-injury (NSSI).
The ACT (Assets Coming Together) for Youth Center of Excellence at Cornell University identified seven reasons for self-injuring: (1) to regulate intense negative emotion, (2) to evoke emotion when feeling numb, (3) to exert self-control or punishment, (4) to provide a distraction, (5) to stimulate a high or rush, (6) to get attention from adults or peers, or (7) to attain group membership.
NSSI is often cutting but also can be burning, bruising, punching, and hitting, and begins primarily in adolescence, when issues of sexual, political, philosophical, and psychological identity are greatest: 14–29 percent of adolescents engage in NSSI. Although some adolescents begin self-injuring as a copycat behavior, it is often associated with distresses in friendship, group loyalties, and substance abuse. Some research indicates that more females self-injure than males, but there is overall agreement that males also engage in the practice.
The reactions to learning that your loved one is engaging in self-injury can be intense. Often, the purpose of self-injury is to regulate intense negative emotion, so the motivation to hide the self-injury can be great. And then there is the shame. Over time, cutting takes on an energy of its own. It becomes a habitual response to emotional dysregulation that can develop an addictive quality. What begins as relatively minor scratching can become an addiction to cutting more frequently, cutting deeper each time, and hiding the cuts and scars. Hiding becomes more difficult, requiring distancing and isolating from loved ones. Steven Lewis offers a TED talk on YouTube, “The Skeletons in My Closet,” that describes his experience with, and recovery from, self-injury:
Most parents want to know how much to worry about their child’s self-injury. The primary issues to pay attention to include (1) the frequency of the self-injury, (2) the numbers of types of self-injury, (3) the location of the injuries on the adolescent’s body, and (4) whether the self-injury co-occurs with thoughts of suicide. If you find that your child is engaged in NSSI, you may want to learn more about self-injury and your options by visiting the website sioutreach.org (Self-Injury Outreach & Support), a collaboration between McGill University and the University of Guelph. The site contains
a number of guides for families, for injurers, and for schools and professionals.
Contacting a professional in your community may help you assess your child’s risk and review treatment options. In the event that the behavior is infrequent, a result of peer pressure, and by a teen who is fairly comfortable with her or his identity, the availability of a caring adult to talk with and explore the options for alternative behaviors may be sufficient.
If the behavior has occurred over a reasonably long period of time, is the result of emotional dysregulation, takes on a variety of forms (e.g., cutting and burning), is primarily in places hidden from view (e.g., breasts, buttocks), and is accompanied by thoughts of suicide, a mental health professional should be consulted to plan for treatment and to rule out a risk for suicide. Unfortunately, this type of dilemma does not respond to short-term therapies. Research has shown that two therapeutic models have shown the most promise with self-injury remission: participation in a 12-month Dialectical Behavioral Therapy program or in an 18-month program that includes an initial inpatient therapy plus weekly individual psychodynamic therapy. And for the worried family member watching the injuring? The temptation is to do something quickly. The solution is to slow down.
Be present. The adolescent cannot come to you if you are not available.
Be approachable. Teenagers do not confide in people who yell at them and shame them.
Be amazed. Adolescent think differently than you do. Leave your ego by the door.
Be comforted. Mistakes happen. Humans are resilient.
Be willing. Ask for help. Bibliotherapy, outpatient therapy, or inpatient therapy is available.