Podcast: Addressing and Preventing Self-Harm in Kids & Teens

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Scott: Hello, everyone. Thanks so much for joining us today. My name is Scott O’Brien, and I oversee McLean Hospital’s education outreach initiatives.

Today’s topic is self-harm, and it’s an incredibly important one. We know that many young people are engaging in self-harming behaviors. For some of them, it’s a way with coping with their emotions, and for others, they’re sometimes unfortunately intending to take their own lives.

Therefore it’s important that folks like you, parents, providers, administrators, healthcare, educators, everyone, it’s crucial that you fully understand how to recognize and assess self-harm.

However, if anyone out there you feel is currently a danger to themselves, please do not forget, call 911. Take them to the nearest emergency room. And the Suicide Lifeline is always available. Their number is 1-800-273-8255.

Alright, Dr. Michael Hollander is here today to help us better understand self-harm in young people. He’s a nationally recognized expert on self-injury and has been treating adolescents and their families for more than 40 years.

He’s also the former director of training at McLean Hospital’s 3East programs, which are focused solely on the wellness of young people. Many years ago, I saw Dr. Hollander present on the topic of self-harm, and he said something that really stuck with me.

He said that self-injury is often a means to end emotional suffering. And I bring this up because it changed the entire way that I thought about self-harm.

It actually made me think about how I once reacted to finding out that someone in my life was engaging in self-harming behaviors. And I remember in that moment I became very upset, and despite the fact that I cared very deeply for this person, I failed to see them as someone who was struggling in such a significant way.

And I’m sharing this today because I would really like for anyone who watches this session, if you’re faced with a similar situation, to react with nothing but empathy for that person. Dr. Hollander, thank you so much for being with us today.

Before we start taking questions, would you be so kind as to share with us the basics about self-harm in young people?

Michael: Sure. So I think, Scott, you raised a critical issue, is that self-harm, non-suicidal self-injury, is usually in the service of relieving emotional suffering. And I’ll say a little bit more about it in a second or two.

And I think it’s also really important that people are able to differentiate between suicidal behavior, that is, behavior that is directed at taking someone, someone’s going to take their own lives, versus non-suicidal self-injury, which is usually cutting or burning.

Years ago, we conflated the two, which was really a shame ‘cause we did our patients a disservice. That is, if someone had multiple cuts on their arm, we would hospitalize them and say, “Well, you must be suicidal.”

And they would, especially young people, would say, “No, you don’t get it. I’m not suicidal at all. Self-injury makes me feel better. It helps relieve my suffering in the moment.” And I think that’s another thing I really want people to understand, is that non-suicidal self-injury actually works. It will make you feel better.

So it isn’t some voodoo that’s going on. There’s science behind why it works, and if someone is interested in that, I can speak a little bit to that. And related to Scott’s point, what we as parents, providers, teachers, see as the problem often the adolescent sees as the solution to the problem.

And unless you are walking side by side with the young person, you’re not going to have much traction in making a difference, in getting this behavior to change. And it really is important that self-injury, for example, gets addressed and changed.

Don’t want to frighten people, but 70% of adolescents who engage in non-suicidal self-injury will make one suicide attempt in their lives. 55% of kids who engage in self-injury will make multiple suicide attempts in their lives.

Now, the difference between non-suicidal self-injury and suicidal behavior is kind of technical, which is, what was the person’s intention? If the intention was to die, it goes as suicide regardless of the method and lethality.

But again, this is a technical definition. If the person says, “I had no intention of dying,” then it’s non-suicidal self-injury. It is rare, but it can happen, that someone self-injures without the intention to die, and of course they self-injure in the wrong place. But that’s really a rarity.

Most people who engage in non-suicidal self-injury know how to do it in a way that isn’t going to cause death. It is a worrisome behavior. It is a behavior that I think needs to be directly targeted in treatment.

I can tell you that when I first started, my line to parents was, “Once we solve all the other problems, self-injury will go away,” which was true. It just took too damn long. Alright, what else do I want to tell you just upfront about suicidal... Okay, so we know that non-suicidal self-injury and suicide has been on the rise.

There has been a dramatic increase in both behaviors since the pandemic. The pandemic has really derailed adolescent development in ways that I think were unfathomable to think about such a thing.

Self-injury in the adolescent population really has varied, but mostly it’s been around 17% of adolescents will engage in non-suicidal self-injury once in their lifetime. Since the pandemic, that seems to be, that’s what it was in 2019.

In 2020, it was 27%, so a dramatic increase. And we’re seeing this also in suicide. For most of my career, suicide was the third-leading cause of death in adolescents. Currently suicide is the second-leading cause of death in adolescents. So it’s a worrisome problem.

It is a problem that parents have a real difficulty managing and trying to understand, which, of course, makes sense. And maybe today, maybe through some questions, maybe I can help people craft some ways of being useful and some ways of not being as useful.

Sometimes in working with adolescents, the best you can do is, for parents, is get a tie and not a win, but you can certainly make things worse. So shall we open up to questions, Scott?

Scott: For people that are out there that are unfamiliar with non-suicidal self-injury, would you give people an idea of what the typical signs are going to be in young people who are engaging in these behaviors?

Michael: Okay, so generally, parents or teachers are usually the first people to find out. And parents sometimes find out by, they find bloody tissues in the bathroom, that their kid is wearing long sleeves and long pants throughout the summer and really is quite reluctant and defensive about why they’re wearing what they’re wearing.

And it just sort of doesn’t add up. Usually self-injury starts privately and is kept out of sight, but eventually parents find out. A kid goes to a pediatrician for a checkup, and the nurse or their doctor finds, finds marks.

Sometimes another adolescent will call someone at the school and say, “So-and-so is having trouble, and I think they’re self-injuring.” So those are the more typical ways that this gets found out.

Scott: Excellent, thank you. If someone like a teacher or someone notices this, is it okay to ask a young person if they’re intending to take their own life?

Michael: Yes, actually it’s an important question to ask, and there has been sort of a longstanding myth that if you ask people about suicide, you’re putting the idea in their head. That’s really not true. It’s not true at all.

If you’re worried about somebody, ask. Just make sure that you’re asking from a place of compassion and curiosity.

And that doesn’t mean that you don’t have to demonstrate some worry, but judgmental communication is going to make things worse. But don’t hesitate to ask about that.

Scott: Thank you. Would you be able to speak briefly about why self-injury, I’ll put it in quotations, works as a coping mechanism for the person engaging in those behaviors?

Michael: Sure, so about 80% of people who self-injure, self-injure as a way of getting themselves emotionally regulated again. So about 80% of these young people have real difficulty managing intense emotions.

Now, another chunk of them, the second biggest chunk of them, are kids who have to up-regulate their emotions. Emotion dysregulation works in two directions.

One is the more typical, you’re flying, you’re jumping out of the seat to your pants, hair’s on fire, can’t stand the way you feel. You self-injure. You feel better. The other group is, “I feel numb and empty. I self-injure, and I feel alive again.”

Biologically, one theory is that at the time of tissue damage, there are opiate-like endorphins that are released into the bloodstream. And those opiate-like endorphins cause a sense of calmness to come over people. So it biologically works.

Now, whether it works in everybody or not in everybody, we just don’t know. It’s also true that about 48%, maybe more, of adolescents who self-injure don’t feel any pain at the time of self-injury.

And some of that, interestingly enough, may have to do with the degree of self-loathing and self-hatred and judgmentalness, and sort of sometimes kids feel this need for punishment. If your mind is working in that direction, it seems that you are, believe it or not, more able to tolerate pain.

And if you were kinder to yourself, you would have a harder time tolerating pain. The other theory that’s around is called pain offset theory.

And the best way to describe this is that old sort of adage about you’re walking down the street, and you see your friend beating his head against the wall, and you say, “Why are you beating your head against the wall?”

And the person says, “‘Cause it feels so good when I stop.” And it actually turns out that that’s true, that if you self-injure, right after you self-injure, you’re going to be calmer than you were before you got dysregulated.

Now, I don’t think these theories are necessarily mutually exclusive. I think both may, in fact, be operative in non-suicidal self-injury.

Scott: Excellent. Some really great questions coming in from the audience, so thank you all for posing these. How can parents or caregivers monitor self-harm behavior without causing issues such as mistrust?

Michael: That’s really, really difficult. And you know, I’ll throw this out there. I don’t think it’s the job of a parent to monitor self-injury. I think it causes more harm than good.

So I think the best way to do this is to find a competent mental health professional who’s going to work with you and your child about addressing self-injury. So let me just anticipate some questions that I know are going to be related to this, which is, should I periodically look at my kid’s body?

And I always say this, if your mental health professional has recommended that, then I would stick with that recommendation. But I’m going to offer the other side to that. I think that that is terribly problematic for a parent to be examining their adolescent’s body.

The degree of shame and humiliation in that is liable to be generated. The juice isn’t worth the squeeze on this one. The second thing that parents often get advised to do is to sanitize the house of every sharp possible.

And I’m not a believer in that for two reasons, but before I say more about that, if the behavior is suicidal, then I think you have to do that.

But if what you’re dealing with is non-suicidal self-injury, there’s just absolutely no way that you can totally sanitize the house from sharps unless the kid is never going to go outside again because once they’re outside, they can pick up any number of things, from going to CVS and buying razors to finding shards of glass on the street and bringing it home.

And then parents then have to do the looking in the backpack and all of that. And to my mind, that creates an adversarial and conflictual climate in an already tense situation. So I don’t recommend that.

The second thing is the world is full of sharps, and we want our kids to be able to live in the world as it is. So taking the sharps away, even if it works, is not useful. And the third thing I would say about that is sometimes self-injury is prompted by seeing a razor so that the self-injury is cued at the front end by the stimulus.

If you take away the stimulus, you’re going to get a decrease in self-injury, no two ways about it, but it’s going to come right back as soon as you re-present the cues. So for example, on inpatient units and residentials, we really do have to take razors away. That’s part of our licensing.

But if a kid reports, “Well, now that you’ve taken the razors away, I feel much better,” that’s a problem because now we’re going to have to figure out what are we going to do when we re-present the razors because the self-injury is liable to come. The urges for self-injury are liable to reemerge.

Scott: Which disorders in particular are most commonly associated with self-harming behaviors?

Michael: Well, there’s certainly developmental disabilities, or they have borderline personality disorder, some variants of bipolar. Some psychotic disorders will have self-injury, certainly PTSD. But let me break this down.

The other thing is that there is a kind of push among mental health professionals to have a separate diagnosis for non-suicidal self-injury because it turns out that some kids who are self-injuring actually don’t meet criteria for any of the diagnoses.

But I think that, two things I want to say about this. If someone is cutting on their face or on their necks, two things people should presumptively wonder about.

This is not like hard diagnosis, but if you’re cutting on, someone is cutting on their neck or on their face, one should think about trauma, significant trauma, or whether the person is developing a psychotic disorder because those are very, very rare kinds of things.

If someone is cutting, really attacking their body, needing sutures, and especially if it’s around their private parts, that’s usually a sign of significant trauma with a capital T in someone’s lives.

But again, you can’t make the diagnosis from the self-injury. It’s just something to keep in your mind.

Scott: Next question has to do with reasons for self-harm and maybe making them a little more visible.

Do some people essentially self-harm in particular ways to gain attention and not in a negative way, in a way that maybe they’re being neglected emotionally, things like that, and they’re engaging in these behaviors in order to draw attention to themselves or be taken seriously?

Michael: There is a small group of kids who do that. For the most part, kids, when I first started getting interested in self-injury, that was the biggest reason mental health professionals and parents thought that kids self-injured, was for attention.

It turns out that it’s a very small group of people. But sometimes there is a group of adolescents who not only feel they need other people to see their wounds as a way of getting validation for their emotional distress.

Some of these very same adolescents need to see the marks in order for them to self-validate about their distress. So yes, that can happen, but it’s generally not the rule.

Scott: Thank you. What about other types, some other types of things that people might consider self-injury, such as drinking or using drugs, things like that? Is that considered self-harm in any way, or is that a completely separate category?

Michael: Well, it’s not non-suicidal self-injury, but it is self-harm. So non-suicidal self-injury, the cutting, the burning, that falls under categories of self-harm. But self-harm can be certainly substance use, eating disorders, things like that.

Scott: Excellent, thank you. So a bunch of questions from people trying to talk or asking about addressing young people who may or are engaging in these behaviors.

Any suggestions for how to approach a young person who you believe or clearly is engaging in these behaviors in a way that would be productive?

Michael: Yeah, I think that you, one, before you have the conversation, you have to make sure you’ve got your mind online and your emotions as regulated as possible. So that’s the first thing that I think is apparent and mental health professionals’ first job, is make sure you’ve got yourself together.

The second thing is to approach this with curiosity. Like, what’s going on? And also to be able to bring to the table some knowledge like, self-injury is usually a sign that you’re having troubles with your emotions or how you feel about yourself.

And can we have a discussion about that? And like, what’s going on? The real thing, if you can work into the conversation, two things that you can work in the conversation, one is that you understand that it works, and, two, here’s the problem with self-injury.

The problem with self-injury is that it makes you feel better in the moment, and you need to validate that that’s actually the case. And it doesn’t, or but it doesn’t help you solve whatever problem’s got you tipped over in the first place.

So one of the analogies that I often use is like if you have a headache, and you take an ibuprofen. Once your headache goes away, you stop thinking about, why did I get a headache? And the same thing is true with self-injury.

Once you self-injure, your mind then moves on down, like you solved that problem. But it doesn’t go back to, hey, what’s going on that I’m getting tipped over on a regular basis? So if you can introduce the idea that it is a short-term solution to long-term problems, you can get some traction.

Scott: You used the word I was going to bring up next, so I’m happy that this is kind of more natural than I thought it was going to be. You brought up how important it is to validate feelings and even why these things are working for them.

Would you speak to us a little bit about validation in general, why it’s so important? And I bring this up, I think it’s incredibly important because it’s one of those things that I think that very few of us were raised with.

Michael: Yes.

Scott: But I have watched how it works, and I’ve tried to incorporate it into my own life. And I am just stunned at how well it works for something that I did not have to pay how to learn to do.

Michael: Right. So, here’s the thing, and let me just say I’ve talked to all my DBT colleagues around the country who are working with adolescents and parents, and we all say the same thing.

One of the hardest skills to teach parents is validation. So validation is simply, in a tentative way, saying that you have some understanding of the other person’s emotional state. That’s all it is. It’s just affirming. It’s not agreeing. It’s not condoning.

Okay, you never have to say, “It makes perfect sense to me that you self-injure, and that’s a wonderful thing.” But you can validate the suffering. You can say, “I imagine you, before you self-injure, you’re really feeling awful.”

That’s the validation, and it’s very, very hard because oftentimes parents are very worried that if they validate, they’re going to condone the behavior.

And you can practice that. I always tell people when we’re teaching validation to start validating other people before they validate their child so they get a little more practice at it. So again, this notion of validation is simply affirming that you understand the other person’s emotional state.

It is always tentative ‘cause you can never really know the inside of another person. If the person says to you, “No, that’s not right,” you really have to let go because validation is always in the eyes of the beholder.

So you may feel that it was the most validating statement you’ve ever made, but if your child says, “Mm, you misunderstand me,” just let it go. This is not a time that you want to be right. This is a time that you want to be effective.

And that’s another question I always ask people to ask themselves, do you want to be right, or do you want to be effective? ‘Cause sometimes they’re not the same thing.

Scott: On the topic of validation, is there a connection between the practice of validation and also building trust with young people?

Michael: Yes, I think that, I always find that people who validate me, and I feel really validated, are people that I’m more willing to trust because I feel they have a sense of who I am and what I’m about, and we’re sort of on the same page.

But the thing about validation is it moves people closer together, which is sometimes why it blows up with adolescents because sometimes that moving closer, for example, to a parent, runs counter to their need to be separate from a parent.

So it can be a little bit tricky, but there really is a link between validation and developing trust. I’ve never worked with a patient who I felt I wasn’t validating. Let me try it this way. When I’ve invalidated patients, they’ve often then moved to the fact that they can’t trust me.

Scott: Thank you. Any suggestions for parents or educators, or actually even, a lot of providers, I imagine, run into the same situation, where they’re trying to get kids who are fairly closed off to engage with them?

Michael: Oh yeah, well, it’s much easier to engage with somebody who’s willing to share. I think some of it, though, has to do with sort of willing to make some guesses about what’s going on, willing to take your time with things, willing to…

I think conversations that go to, “If you don’t tell me anything, I’m not going to be able to help you,” I have found those to be dead-ends in my own practice.

And while there’s a limit to this, I’m willing to have some extended chit-chat about things to move into topics. It took me a long time in my career to get to that, partly ‘cause I’m from the New York metropolitan area, and as a culture, it’s more direct.

But, I think just taking your time. Freud was once asked, “How do you get people to talk to you?” And he says, “Oh, it’s very easy. Things just ooze out of them.” But in order for things to ooze out of them, you really have to be patient and work at the kids’ pace.

Now, it may turn out that after a while, you’re not getting anywhere, and after several months, it may be that this is not the right treatment, or this isn’t the right time for treatment. But some patience is really required.

Scott: On the topic of treatment, which are proven to be most effective when addressing self-harm in young people?

Michael: Well, DBT is the gold standard. However, mentalization-based treatment, general psychiatric management, even transference-focused therapies, all of the treatments for, quote, for borderline personality disorder have shown to be effective in ameliorating self-injury.

Scott: And saying DBT is the gold standard, so let’s go there if you don’t mind. What exactly does treatment look like?

Michael: Oh, okay, so, treatment in DBT, there are four components of it. One is individual DBT therapy. The second is a DBT skills training of some sorts. Usually that’s done in a group, but it doesn’t have to be in a group.

It can be an individual DBT skills trainer. Between-session contact between the patient and the therapist. That is, the patient can reach out to the therapist for skills coaching, which is a thing in and of itself.

And the fourth thing is that the therapist has to be on a DBT consultation team. That’s orthodox DBT. The treatment starts with an assessment about what are the problems here that we’re going to work on.

And while I think this has changed a bit, I’m not sure Marsha Linehan would’ve gone for it, someone has to make a commitment to take suicide and self-injury off the table in order to get into DBT.

And you generally have what’s called the pre-treatment sessions, which are the first four sessions in DBT, to get the patient committed to the treatment and taking non-suicidal self-injury off the table.

Now, that doesn’t mean that it’s a promise you’re never going to do it. It means that we are going to address this, these behaviors, when they show up, and we’re going to address them in a way that makes them really a priority in the treatment.

One, Marsha felt this way because, one, you can’t treat people who are dead, and, two, that self-injury, because of its link to suicide, was something that needed to be addressed right up front.

So those are the highest-priority targets in DBT. So DBT is a hierarchical targeted treatment. So life-threatening behaviors and violent behaviors are the most important targets.

The second highest targets are therapy-interfering behavior, which is any behavior that interferes in the treatment, whether it’s on the part of the therapist or the patient.

And then there are the life-interfering behaviors that are critically important and really holding people back, and the very behaviors, by the way, that all of the treatments are the worst at helping with.

So all of the treatments are pretty good at self-injury and suicide and getting people into therapy. What we’re really not so good at is the more psychosocial, sort of how to hold a job, how to have better relationships. Those things over time don’t hold up as well as the higher-priority targets.

Scott: When someone agrees to engage in therapy, and you say that self-injury’s off the table, I imagine that people who have been engaging in self-harming behavior have been doing this for quite a while to help cope.

Michael: Yeah, yeah.

Scott: Is there some kind of a strategy that is offered to them, some kind of substitute behavior that’s recommended?

Michael: No, no, there’s no substitute behavior, but what you can say to someone is, “How long can you take self-injury off the table? Can you take it off for an hour? Can you take it off for a day?”

And I think this is another thing that has gotten lost. Our goal, of course, is to get the person to take these behaviors off the table for some period of time, but it’s just not realistic if somebody has been self-injuring seven days a week to say, “Okay, take self-injury off the table.”

The question is how long can you commit to taking self-injury off the table? And when I was seeing more adolescents than I am now in DBT, I would have adolescents where we could go a half a day.

I would take a commitment, can you take self-injury off the table for four hours?

Now the thing was then I had to be willing three hours and 45 minutes into it to get back on the phone or get with the person to say, “Where are we on commitment? Can I get another four hours? Oh, okay, you gave me four hours. Can you give me six hours?”

kind of thing, and we build up. So it isn’t about substitution. I have some problems with substitutions, like some people recommend putting an elastic band on your wrist and snapping it.

But I’m worried that if you snap it hard enough, you’re going to get the same lift as if you cut yourself. Drawing cuts on your arm just doesn’t seem to me to be a viable substitute. I’d rather much work with whatever commitment I can get and work from there.

Scott: I know you typically work with more teens and adolescents, but at how young is it possible for children to start engaging in self-harm behavior?

Michael: The age of onset is 11 to 15, 11 years old to 15. But I’ve recently come across some kids who started self-injuring at age nine. So I think that this is a behavior in part because it’s in the media and so much a part of teen culture that I think preteens are picking up on it and reaching for it.

Scott: Thank you. As a provider, if a client discloses that they are engaging in self-injury, and they’re a minor, do you always recommend disclosing this information to parents or caregivers?

Michael: That’s a really tough question, and it really depends on a couple of things. One is if you’re working in an agency, and they have a policy about that, then you actually have to follow the agency policy.

Agency policy always trumps DBT, for example. So if you find that out, there are a number of things you can do. You can talk with the adolescent and say, “Your folks really actually need to know this.”

I would feel really awful if I was working, say, with a 16 year old who was self-injuring, and I didn’t know that at the outset, but I kept that confidential, and the parents found out and came in and asked me, “Did you know my kid was self-injuring for the last three months?”

And I say, “Yeah, I did. You know, confidentiality.” I don’t think that’s useful. I think the way around this actually is for therapists to be really clear about, with the kid and with the parents, about their criteria for confidentiality.

I think just saying, “Unless you’re going to kill yourself or you’re going to hurt someone, everything you tell me is private,” I think that that’s a mistake often for those of us working with adolescents. And the prime example is self-injury.

A prime example is substance abuse. So what I say is, “By and large, we’re going to keep things private, but I also feel we’re going to have to discuss what I think your parents need to know in order to be effective parents.”

And I think one of the things I would say is, “Self-injury is one of those things that your parents need to know.” Then I would bring the parents in and say, “This is what’s happening. Your child and I have an understanding. We’re going to be working at this.

In three months, I’m going to bring you back in, and we’re going to talk about whether we’ve made progress on this. If we’re not making progress on this, I’m going to let you know that we haven’t been able to get on top of this, on top of this behavior.”

So now I wouldn’t do that if I really, I mean, there’s always caveats. If I thought that the kid, when he or she disclosed this, was liable to be, more liable to getting some sort of verbal or physical abuse, that’s a different story. But by and large with most parents, I think you can work this in.

But I sure wouldn’t want parents to find out that I knew that their kid was self-injuring and that I didn’t say anything about it in the same way that I’m going to tell parents in that meeting, “I’m not going to tell you every time your kid self-injures because, for goodness sake, my guess is your kid is going to stop telling me when they self-injure.

So you’re going to have to tolerate some distress for the next 90 days.”

Scott: Makes perfect sense. Thank you. Any differences in self-harming behavior related to gender or race?

Michael: Not so much anymore. Certainly more, in clinic populations, it was girls self-injured more.

But as gender becomes less bimodal and for lots of other factors, it’s turning out that gender is not so much a significant determinant of who’s self-injuring and who’s not these days. Still more girls than boys, but it’s evening out.

Scott: Coming back to before, do you or do you not disclose to parents or caregivers, someone’s asking about if you were going to address this with them, and they don’t understand the behavior, are there specific recommendations that you make to them?

One, explaining it to them, but also saying, explaining to them how to behave or react in a helpful way with this young person? Versus what are the things that you recommend they absolutely don’t do when they get home?

Michael: Oh, well, I certainly wouldn’t tell kids, tell parents after this has been disclosed that they ask three times a day on self-injury.

I would tell parents not to start snooping around in people’s rooms and looking at diaries and whatnot and not to take the sharps out of the house or to be looking over somebody’s body. While all of that sort of makes some kind of sense, I think it just makes things worse.

What I tell parents is, “This is really tough, and your job really is to tolerate your own distress about this, that this is a problem you actually can’t solve. And it’s a problem you can’t prevent from happening.

Only the kid can stop this behavior.” I mean, I’ve seen kids in psychiatric hospitals in four-point restraint find ways to self-injure. So it just... It would be great if there was a way parents could stop it, but there just isn’t.

Scott: If an individual in a child or teen’s friend group is engaging in self-harm, do we know if that increases the likelihood that others in that group will engage in that behavior?

Michael: Yeah, we do know that these kinds of behaviors are, there’s a contagion effect, that if your best friend is self-injuring, and other kids are self-injuring in your friend group, you’re more likely to self-injure.

The problem you have or that parents have is that they often try to interrupt the friendships. And while again, that’s something that makes sense, I don’t think it’s possible to do unless you’re going to move out of state or out of the country.

With social media, phones, computers, it’s really hard to do. In some ways the other piece of this is that, like with substance abuse, it’s, people find their group. So it’s less about being pressured into something than being in a group where this is sort of, more of interpersonal currency.

I can tell you that most kids who are in friend groups where there’s self-injury, most of the time, the friend group is anti-self-injury, and they all try to help each other, ineffectively, stop self-injuring.

And that’s a whole other kettle of fish. But I have not seen much success when parents try to end a friendship or extricate their child from a particular friend group.

Scott: Yeah, that makes sense. Would you speak to us briefly about the things that some of us might consider self-harming behaviors, such as like, a lot of, I would say, emotionally dysregulated young people are going to have anger and things like that.

And they might punch things or kick things, things like that, which may appear to be self-harm to some people, but at the same time, it’s probably something else. Would you speak to the similarities and differences to us?

Michael: Sure. If I’m, and this is more boys than girls, I’m really, really mad, and I punch the wall, that’s probably not going to be non-suicidal self-injury.

It’s certainly stupid and self-harm. I spent a little time, and I still do, boxing, and I’m forever saying to somebody, “The wall is going to win every single time.” If you punch the wall, it’s just going to bust up your hand. But that’s really not self-injury.

That’s generally kind of impulsive behavior. And by impulsive behavior, what I really mean is that you’re so full of pent-up anger, you just, bam, just move into action quickly without thinking about the consequences.

Self-harm is more deliberate than that, okay. Usually around this kind of topic, people want to know about tattoos and piercings, and the answer is no, they are generally not signs of self-injury unless somebody under the sway of emotion dysregulation begins to tattoo themselves.

Then it might be under the category of non-suicidal self-injury. But if you’ve been planning and wanting a tattoo for months, and then you go and get it, it doesn’t meet criteria.

Scott: Thank you. This is from me, not from the audience, but it’s something that I saw you speak, again, years ago. And one of the things you brought up was the importance of young people being able to label and identify emotions.

Michael: Yeah.

Scott: It’s really stuck with me ever since, and I started digging kind of into it, and I’ve had more conversations with male friends of mine about this than pretty much anything else related to mental health because it was one of those things that at the time, I was like, “Oh yeah, do I do this?”

And then I realized it’s one of the things I struggled with the most, even not only growing up, but also as an adult, which is really embarrassing to say as like a college-educated individual, that I can’t identify and label my own emotions.

Would you speak to us about this just for a minute and talk about the importance of this and also how we can help young people do this?

Michael: Okay, so, the thing about, By and large, the kids who self-injure really have trouble identifying and accurately labeling their emotions. And this is really problematic for a number of reasons.

First is our emotions give us information, and if we can’t label and get that information from our emotions, we’re sort of lost in the world. The second thing is that there’s a benefit to being able to accurately label and identifying your emotion. And that is that it lowers the temperature on your emotion.

So just being able to notice in some metacognitive kind of way that you’re angry will, in all likelihood, lower your degree of anger in part because that labeling and identifying the emotion gets your prefrontal cortex on board and online.

And when that gets online, it helps modulate your emotional experiencing. So we have a skill in DBT called mindfulness of current emotion, and it is an emotion-regulation strategy. And that is what we’re going to do, is we’re going to look at, oh, I’m feeling something.

What are the sensations in my body? What are my thoughts? And what is the emotion telling me to do? And if you do that, you become slightly more regulated. So it’s critical that you’re able to do that.

And you’re not alone in not knowing exactly what your emotions are. This, I think, has been historically a problem for men, since men weren’t supposed to have much emotion anyway, so let’s stamp it out when they start to arise.

Scott: A couple of questions from folks asking about, essentially at a time when mental health services are, lots of wait lists, people struggling to find appointments with providers, if they even have providers in their area that are capable of providing treatment around self-harm.

How can a parent or caregiver support a child if they are engaging in any kind of self-injurious behavior while waiting for treatment to become available? Should they go to the ER? Should they talk to their pediatrician? Are there other resources you recommend?

Michael: Oh boy.

Some problems don’t have great solutions, and the lack of availability and affordability of mental health care is a significant problem. I think, for parents, learning and getting really, having a great facility with validation, I think will go a long way in helping your kid feel understood, which in fact might help in two things.

One, having you become a greater resource for them in terms of helping them solve their problems, or at least talk with you about their problems, and that validation is also a way of helping someone get in touch with what they’re feeling.

Okay, so, for example, if a kid starts talking about being overwhelmed, and you can say, “Well, it sounds to me that, yeah, I got that you’re overwhelmed, but it sounds like you’re overwhelmed with worry. Or you’re overwhelmed with sadness.”

That’s in the service of helping build some emotion regulation skills. That’s about what I can say. I mean, there are things that parents can do or try to do around reducing emotional vulnerability, emotional vulnerability.

But those skills are around like getting enough sleep, staying off alcohol and drugs, getting enough exercise, all the kinds of things that you’ve been probably struggling with your kid anyway about. But I think it is useful to bring that up.

I would bring it up, though, as in, here’s the science behind it. For example, we know that with adolescents, or at least for a chunk of adolescents, that regular exercise will work just as well as an antidepressant.

And so getting your kid involved with you would be great in some sort of physical activity on a regular basis. Sometimes this is easier said than done, but things like that. But there aren’t really a lot of, I don’t have a lot of great solutions to offer to the problem of lack of mental health professionals.

Scott: That’s alright. Thank you. So a couple people, different people, asking about getting better at the practice of validation. Before I ask you for more resources, I will note that we did host a session back in the spring with a colleague of Michael and mine all about validation.

So we’ll make sure we share that in the recap email that goes out. But for this session, I’ll link over to that. But Michael, any suggestions around books or other resources for adults who are looking to learn more about it and also just get better at it?

Michael: Okay, so I’m always hesitant to do this, Scott, but “Helping Teens Who Cut,” which is a book that I wrote, has a whole bunch of chapters in there about validation and levels of validation.

Alternatively, if you just Google validation, people like Alan Fruzzetti, who’s at McLean, and others are going to come up, and there’s going to be a whole bunch of worksheets and what not about validation. So the information is out there.

Scott: Thank you. If self-injury is not addressed, does it worsen over time?

Michael: That’s a great question. It may not worsen. It may stay steady state. What we know is that the high-action behaviors like suicidal behavior and self-injury generally dissipate over five to 10 years. I mean, that’s generally the life of this.

So they persist, but eventually they disappear. The problem is that if you’re using self-injury for that period of time, you’re not learning how to manage your own emotional experience very well. And so you’re really getting behind the eight ball in your life.

It’s best if this behavior can be addressed, and sometimes it can be remediated in as short as three months, depending on how long the person has been self-injuring.

For example, if you can catch self-injury in an early adolescent, you can sometimes really treat it successfully in a relatively short period of time. The longer that someone has been using this as a coping mechanism, the harder it is sometimes to get it out of the behavioral repertoire.

Scott: Thank you. We’ve had multiple people write in with a similar concern, and it’s very, very concerning, but I’m also very much appreciative that people who are asking these questions have the attitude that they do towards it.

People saying that, I think they’re all educators, saying, “What do you recommend doing if parents are not acknowledging the self-harming behaviors and are not seeking treatment for a child or teen?

How can someone who’s working in a school, whether it’s an educator, an administrator, how can they help support that student when the parents are not doing what they should be doing to support them at home?”

Michael: Well, let me start with the most draconian intervention.

It would seem to me if someone were, if I were an educator, and I had a kid who was really self-injuring on a regular basis, and the parents were minimizing it, I might let the parents know that I would need to let protective services know about this as a mandated reporter.

Because there’s a kind of a medical neglect here that this is, while it is prevalent in adolescents, it’s not normative in adolescents. And it does most often bespeak some sort of emotional suffering, if not a diagnosable mental illness. So that’s one thing.

The second thing is it depends on what the parents’ denial is about. If the parents’ denial is, and I’ve worked with parents who have come in and said, “Hey, well, look, self-injury, every adolescent self-injures, so this is normal behavior.”

Then it might be that I might want to do some psychoeducation with the parents about the fact that, “No, this is not normative behavior. It doesn’t meet any criteria for normal adolescent behavior,” and see if I can’t move them that way.

If the denial of the parents is rooted in the fact that they just can’t bring themselves to tolerate how awful they feel about their kid’s self-injuring and are minimizing it, then I might suggest that the parents speak either to their clergymen, family doctor, or another mental health profession just to get some sense about this.

So I think that’s the best I can come up with about that.

Scott: That’s great. Is there a connection between ADHD and self-harm?

Michael: It wouldn’t surprise me if there is a relatively high correlation, relatively high correlation between ADD and self-harm, in part because kids with ADD have a really hard time slowing down enough to think things through.

And to the degree they get emotionally dysregulated, I think they might be more apt to reach for self-harm. So it’s usually on the list of diagnoses that correlate with self-harm.

Scott: Thank you. One more question. Someone was asking, saying, “Aside from being empathetic as a parent toward a child who is engaging in this behavior, any other tips that you generally recommend for parents who are kind of new to this?”

Michael: Yeah, make sure you take care of yourselves, that it’s coming to terms with what the limitations are as a parent and tolerating your own distress.

The number of parents who come to us and have dropped all of the things in their lives that were nourishing to them in the service of, “How can I go out to dinner with my friends when my kid is self-injuring?”

I tried to early on work with people about, “Well, no, you got to go back out to dinner.” But what I’ve come to is I generally say to people, “Well, why don’t you see how this goes? Give up everything for six weeks. If it helps your kid with self-injury, keep doing it.

If it doesn’t help your kid with self-injury, go back out and do the things that you’re going to need to do because your own resilience is going to be paramount in making this a successful journey.”

Scott: Before we sign off, I do want to thank the audience for being with us today, both your presence and for all the fantastic questions.

Clearly there’s a lot of very compassionate people out there asking these questions, and I have to say I very, very much appreciate you spending the time with us and being here to kind of help support the people in your lives.

Dr. Hollander, thank you so much for being with us today. Lots of appreciation from the audience for your time and for your expertise.

Michael: Thank you, Scott, bye-bye.

Scott: Yes, bye-bye.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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