Asking Young People About Self-harm

One of the challenges of doing therapy, particularly with young people, is maintaining a state of ‘binocular clinical vision’ – keeping one eye on what we see, hear and know, and another eye on the reality that our awareness is limited, that there is much that we cannot comprehend about our patients.

Shakespeare wrote, ‘Into a thousand parts divide one man,’ and as clinicians, we are generally privy to very few of those parts.

What makes maintaining binocular vision even more challenging is that we often want to protect ourselves from exposure to the more disturbing parts of those whom we minister to. This inhibits the possibility that an important ‘missing piece’ will ever enter the therapeutic conversation.

Self-injury, stigma and shame

When taking care of youth, one of these too-often missing pieces is self-injury, which most commonly takes the form of cutting oneself with glass, razor blades or other sharp objects, but can also include burning or hitting oneself, repeatedly scratching or picking scabs, pulling out hair, eyelashes, or eyebrows, dangerously inserting objects into one’s body or overdosing on medications.

The shame and stigma associated with self-injury is profound. Countless young people have confided to me their most private thoughts and secret behaviours, their most embarrassing fears and mortifying wishes, and yet never mention the fact that they harm themselves. I have even had patients disclose explicitly suicidal plans but hesitate to acknowledge self-injurious behaviour that is far less dangerous and yet, for many reasons, far more humiliating.

Among the range of issues that bring young people into treatment, self-injury is especially difficult to address because those who harm themselves usually carry with them tremendous ambivalence regarding whether they want anyone else to know – they are characterised by a desperate tension behind the wish to conceal and the wish to reveal.  

Also, self-injury, like any behavioural problem, is actually designed to solve a problem. For example, many patients have admitted to me that self-injury effectively crystallises their vast, oppressive emotional pain into more consolidated, concrete physical pain, thus making it easier to manage. I have frequently heard that the psychological relief that self-injury provides is far more immediate, and often more enduring, than relief provided by medication or recreational drug use. So bringing self-harming behaviours to light could, from a patient’s perspective, run the risk of then being deprived of a mechanism that serves an important palliative purpose, despite its dangers.

Discussing self-harm: a three-stage framework

With this in mind, it is important to ensure that the possibility of self-injury is brought gently but directly into the clinical conversation. We have to make it clear that anything can be talked about, and that we will not be fazed by or critical of whatever is divulged. 

In my practice, I keep in mind a flexible three-stage framework of questioning when it comes to self-injury.

The first stage is direct: “When you are feeling overwhelmed, have you found yourself harming yourself in any way, or have you ever had thoughts of doing so?”, and then providing some examples of self-injury (such as the behaviours noted above).

If I receive a rapid (and not quite trustworthy) “No”, I might move on to the second stage: “If you ever did harm yourself, or consider doing so, do you think you would be comfortable telling someone, whether it was me or another trusted adult?” This acknowledges for patients the reality that we are well aware that they are not going to share everything with us, and that behind the decision of what to disclose in treatment, and what to keep under wraps, lies a complicated calculus.

Finally, I will often travel to the third stage and ask patients if they know of any friends or acquaintances who intentionally engage in self-harm. Children and adolescents may be more likely to talk about “someone else” than about themselves, but, as we know, that “someone else” may be a thinly veiled version of themselves, or at least of a segment of their identity.
Surfacing the reality of self-injury is not, by itself, a panacea, but it does begin to lay the groundwork for healing. Shifting the therapeutic dialogue from, “Let’s figure out what’s wrong with you,” to “Let’s figure out what you’re trying to say,” enlarges the panorama of curative pathways, and expands the likelihood that our patients will find new, less-injurious and more growth-promoting, sources of coping, comfort and consolation as they carefully chart their way through life’s most perilous passages.