When it comes to self-harm, there is a fine line between sending the message of accepting a behaviour and encouraging it, writes Snita Ahir-Knight
In my clinical work, I often encounter young people who self-harm.
So I have been thinking about non-suicidal self-harm – young people who often self-harm to help them cope with overwhelming emotions and thoughts.
This is distinct from young people who hurt themselves with the intention to die.
Even more specifically, I’ve been thinking about the internal and external dialogues that may surround self-harm.
It is natural to be distressed when you find out someone you care about is self-harming. You may want to protect them. So it is understandable to say to yourself you must encourage them to stop.
One way to try to get them to stop is to encourage them to replace the self-harming behaviour with something that causes less or no physical injury. For example, flicking the skin with a rubber band, holding an ice cube against the skin and drawing red lines on the skin. These are sometimes called ‘substitution methods’.
But there is a problem. There has been little research into whether substitution methods are effective when it comes to self-harm. When UK researchers asked young people about using substitution methods instead of self-harming, most said they did not find them helpful. Only a few young people were asked so more empirical research is needed.
But hearing the views of some young people got me thinking further: how do young people perceive being told to stop self-harming?
I don’t know in all cases. But I still have a general worry.
Encouraging a young person to use substitution methods may give the impression there is something unacceptable with their initial self-harming behaviour.
When young people feel accepted they are less likely to hide their feelings and behaviour. And more likely to accept help if it’s needed.
Yet in many cases self-harm is a coping strategy. Young people use self-harm because, while there may be negative consequences, it is a helpful tool. Seen in this light, self-harm is an understandable behaviour. It serves a practical and helpful function.
Of course, a young person may weigh up the costs and benefits of the original behaviour against the substitution method and decide the substitution method has less of a cost to them. But if a young person finds self-harm an effective tool and this outweighs its costs, being told to substitute the behaviour risks sending the message that self-harm is not acceptable.
This may make the young person feel unnecessary guilt and shame. They may also feel misunderstood. This may be because they feel self-harm is their only effective coping tool, so they are not able to imagine managing without it. This may result in the young person saying to themselves they are being judged and made to stop. So they hide the behaviour and how they are feeling.
When substitution methods occur alongside therapeutic interventions, the young person may feel unable to deal with the underlying problem without self-harm. This may be because they are not receiving an effective therapeutic intervention, they are not seeing the right therapist or they have not built trust in the process. This may result in the young person saying to themselves these people cannot help. So they disengage.
How can we keep young people safe and not risk these consequences?
One possible solution is to use harm minimisation methods. These set out to reduce the physical injury caused as the person continues to engage in self-harm. For example, someone harming themselves by cutting may be taught how to clean cuts and have access to clean tools to cut themselves with to avoid infections.
Harm minimisation methods are less likely to send the message that self-harm is not acceptable, because the young person is not being asked to stop or replace their behaviour completely. Instead they may perceive the message to be that they are being kept as safe as possible by reducing the risk of physical injury.
But maybe you are uncomfortable – maybe this is encouraging them to self-harm.
There is a fine line between sending the message of accepting a behaviour and encouraging it. For example, allowing a young person to keep their own clean tools, if they want to, may send the message that the behaviour is acceptable, while actively providing the tools may send the message of encouraging the behaviour.
This is a fine line that is trod at other times.
Consider binge drinking.
Many young people binge-drink – mainly not to cause themselves direct harm but for other reasons. Maybe to fit in, to stop themselves feeling anxious at a party or because it is fun. Binge-drinking often causes negative consequences and despite being told the dangers, young people will often continue. This behaviour is commonly-accepted because it is recognised that youth may engage in risky behaviours as part of their development.
So young people may not be stopped from going out drinking. Instead, if they want to reduce the risk of physical injury, they may agree to eating a meal beforehand, drinking a lot of water and having a sober driver. The hope is they will be kept as safe as possible by reducing the risk of physical injury. Encouraging them would be me slipping them $20 and telling them to have a couple on me.
So it is possible to show acceptance without encouragement.
And when young people feel accepted they are less likely to hide their feelings and behaviour. And more likely to accept help if it’s needed.
Where to get help
1737, Need to talk? Free call or text 1737 any time for support from a trained counsellor
Lifeline – 0800 543 354 or (09) 5222 999 within Auckland
Samaritans – 0800 726 666
Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO)
What’s Up – 0800 942 8787 (for 5–18 year olds). Phone counselling is available Monday to Friday, midday–11pm and weekends, 3pm–11pm. Online chat is available 7pm–10pm daily.
Kidsline – 0800 54 37 54 (0800 kidsline) for young people up to 18 years of age. Open 24/7.
thelowdown.co.nz – or email firstname.lastname@example.org or free text 5626
Anxiety New Zealand – 0800 ANXIETY (0800 269 4389)
Rural Support Trust – 0800 787 254 (0800 RURAL HELP)
Supporting Families in Mental Illness – 0800 732 825