Understanding and Responding to Self-Harm

Written By Dr Pooky Knightsmith

April 21, 2021

There are many reasons why someone might self-harm

Two injuries may look the same and the motivations might be entirely different. There many different needs self-harm might be meeting, some commons ones are:

To feel control of one aspect of their life
To punish themselves
To access care and listening
Physical pain is easier to manage than emotional pain
To appear ugly to an abuser
To feel real and connect with the world (e.g. if in the bell jar of depression)

It can become a cycle

Self-harm can provide temporary relief to distressing thoughts, feelings and experiences, but the act of self-harm can add to their guilt, shame and distress which, after the temporary relief has passed often means their problems feel bigger, not better. If they have no other ways of seeking this relief, they may turn again to self-harm.

Self-harm meets a need and so the child returns to it
The cycle is self-reinforcing
If self-harm continues it becomes normalised and habit forming
It is easier to break the cycle if we intervene earlier
Simple concrete discussion about the self-harm helps us understand & builds bridges

The cycle of self-harm as described by Pooky

There are different ways to break the cycle

We can intervene at any point in the cycle in order to begin to break it – it can be helpful to be working on more than one area at once. Things we can explore include:

Big feelings: What is the source of the big feelings, can this be changed or managed?
Can’t cope: Can we increase the child’s capacity to cope by e.g. widening their window of tolerance, boosting their resilience or teaching healthy coping strategies?
Crisis moment: can the child learn to get through the first 60 seconds safely?
Relief: is there anything else that might generate a similar feeling without causing harm?
Guilt & shame: exploring this can provide the motivation for change

The first minute matters

For many young people, self-harm happens in moments when they become overwhelmed with distress. During these moments of acute distress our brains aren’t in a good place to make decisions and problem solve but this high distress state will not continue indefinitely and if we can buy even a little time then the brain and body will begin to calm and the chid may be able to avoid harming themselves or to do so in a more controlled manner.

During moments of overwhelm focusing on simply getting through the next minute can feel more manageable. It doesn’t matter how we do this, just anything to get us through – I’ve shared a few ideas on this here and some suggestions are listed below:

Set a one minute timer and watch the time pass
Count from 100 to zero backwards
Listen to your favourite song from beginning to end
Play a round of candy crush or other game you have on your phone
Try to remember the names of everyone in your first class at school
Count all the green things you can see
Access your self-soothe box (you would have made it ahead..)

As you can see, anything goes, it’s just about buying that first minute! Planning for the first minute is an important part of ‘safety planning’. There is a sample safety plan you can adapt at the end of this doc or you can use the excellent NHS funded site stayingsafe.net (aimed at suicidal adults but I would recommend it for use with adolescents who self-harm too).

Finding other ways to fight the feelings

If we can understand the urge behind the need to self-harm in those moments of overwhelm, we can often find alternatives which somewhat respond to that urge. The substitutes often won’t meet the need as well, especially at first and if the self-harm is well established, but they may offer something of a viable alternative.

We need to understand the underlying urge or we’ll scratch the wrong itch
Two injuries might look the same but be doing different things for different people e.g.
- I need to SEE my pain
- I need to CALM and soothe
- I need to feel REAL
- I need to feel in CONTROL

Could all explain a similar looking pattern of cutting – but all will require different alternatives.

n.b. there is emerging (but compelling) evidence that commonly used harm minimisation strategies such as snapping elastic bands on the skin, may do more harm than good so please don’t recommend them. Here is the research paper. The team who developed it are excellent and working further on this.