Self Harm is Sometimes a Step on the Healing Staircase

Trigger Warning: self injury 

Non suicidal self injury (NSSI) or self harm is a concealed topic for a lot of teens and young people. It is often extremely distressing for parents to learn that their child or teen is using cutting, scratching, burning, or other forms of self harm to release stress and feelings. If you’re a parent reading this, you’re not alone. This blog post is a little primer on some ways to talk to kids about NSSI, some tips on when to go to the hospital, and the ways that self harm can be treated (and my personal treatment approach). 

Cornell University has a fantastic website about self injury behaviors, the summary is that there is a difference between self harm and suicide attempts. Most self harm does not require more than at-home medical care (like washing the injury, an antiseptic, and maybe a bandage) but some that require sutures or debridement are more significant concerns for suicide. Self injury at its core is a maladaptive coping skill rooted in how our bodies release hormones. 

Those hormones are thought to be part of the endogenous opioid system (EOS) in the body that regulates pain and release of endogenous endorphins to mitigate pain but have a secondary response of elevated mood or decreased negative emotions (like anxiety). Another suspected part of NSSI is in the limbic system and the way our brains associate stress and emotions, as well as memory. When things are working smoothly our brains are able to downshift quickly out of the heightened state that stress can trigger (stopping the flow of cortisol, adrenaline, etc.) but when our brains cannot downshift, some experts believe that the use of NSSI is a mechanical way to down shift the brain and body by releasing a flood of counter-acting chemicals possibly through the EOS or parasympathetic nervous system. When a process works and causes pleasure (the relief of not being in a heightened state anymore) a new neural network is formed that our brains seek in similar times of stress. 

I am pretty sure I say this at least once a session, but here you all go in case you haven’t heard me say it recently: our bodies see stress as stress even though we know that bad stress and good stress (excitement, motivation, anticipation) are different to us logically. The difference is about how quickly our body downshifts after the anticipated event occurs. Some things that can make folks more sensitive to stresses are what Cornell has identified as A-typical self processing and A-typical social processing. Some examples of that are low self esteem and over self-estimation of the significance of a negative behavior. A-typical social processing might look like extreme sensitivity to perceived or real social exclusion from peers. All these examples are part of what the Cornell research shows to be neural differences in folks who exhibit self harm behaviors. 

So, now that we have basics covered, what do you do if you learn that someone you love is engaging in non-suicidal self injurious behavior? This is easier said that done but...don’t panic, don’t call them out, and don’t assume that it was a suicide attempt. Instead, try asking some gentle questions like, “can I get you a band-aide or an ice pack for that cut on your arm?” Cornell has a great list of questions to ask but my favorite is this, “This [the cut on your arm, etc.] scares me because I love you and I want to help you but I don’t know how.” If your child has a significant injury that is deep, or infected, or runs parallel to the long bones in the body (e.g. goes from palm to elbow), is associated with ligature marks to the neck, bruising to the eyes, or if your child has a history of suicide attempts please call the crisis line or head to the nearest emergency department. But again, most NSSI is just that, non suicidal. 

Other great ways to talk about self injury include, thinking about self harm from the harm reduction model. The harm reduction model is typically used in substance abuse treatment or public health treatment approaches to substance abuse. I like to correlate the two because of the biochemical similarities of addictive behaviors and NSSI. Harm reduction models typically center on five basic components: it’s evidence based, harm reduction does not encourage the behavior nor force someone to stop the behavior--it is a fundamentally non-judgmental approach, understanding that people experience benefits and negative consequences from behaviors, focus on immediate improvement on present quality of life and reducing the harm from a behavior in the immediate, and focus on immediate to offer a lot of choices to change or mitigate some harmful factors of behaviors. 

If this sounds excruciating to you--Claire You’re bonkers! My kid is HURT! This can’t happen at all anymore!--I hear you. I get it, it does sound bonkers. But, when we think about why kids self harm some of it is a biological response to the inability to downshift after stressful situations. And what does that fancy sentence really mean? Feeling out of control because of a flood of chemicals and hormones in the body. If we take away the singular sense of control a child has to self-regulation without replacing it (see here’s where those options come into play as part of harm reduction) that leaves everyone in a scary place feeling much more alone and more out of control; plus it might cause an increase in stressy brain chemicals. 

So here we go, let’s think about the self harm behaviors as a staircase. We are always trying to walk down the stairs to healthy coping mechanisms. But because this is an MC Escher stairway, it goes indefinitely. So sometimes we step up a step or two and have to walk back down. There are always more escalated behaviors that could happen. So let’s focus on the fact that your loved one didn’t do those and reinforce other skills that person has to use in the future. When we use new coping skills the hope is to create a new healthier neural pathway that possibly activates the EOS or parasympathetic nervous system or the forced downshifting. 

*everyone’s staircase looks a little different, and that’s okay

When we think about how we can have conversations about using healthier coping skills while still validating the reduced harm the person has engaged in we decrease the shame cycle. (A personal example: I binge ate an entire bag of chips and I’m embarrassed and ashamed because I was not hungry and just didn’t stop. So to comfort myself I eat a whole bag of cookies because my sneaky brain says that eating things I love is comforting and releases dopamine. So instead if I had replaced the eating a whole bag of cookies with going for a walk, meditating, writing in my journal, hugging my dog, or drinking a glass of water I would work on creating a different neural pathway. But in harm reduction--I would eat just one or two cookies for comfort AND do one of the other activities. Over time I would decrease to no cookies and only using a different coping skill until I replaced the binge eating in total with a skill that can sooth the need the eating was filling. Pun intended, eating is filling.)

When talking about NSSI, try to remember that we are all on a staircase and doing our best to walk down it. If your kid has shown you that they self injured--they are trying to walk down those stairs and just need a handrail. That can come as the form of nonjudgmental curiosity, offering to help find a therapist for your loved one, or simply listening and remembering that there is a chance for change.