The phrase “self-harming behavior” may call up images of troubled teenagers with cuts on their arms. But self-injury can occur for people of any age, in children, adolescents and adults, whether male or female.  This is not at all a teenage fad!

People who self-harm or cut are people who are in pain. As therapists, one of the important things we notice is the emotional pain — not just the outward expression of it. A trauma-informed approach begins by building trust and safety for the person using self-harming behaviors. We do this by offering the understanding and compassion they need to begin facing the trauma within.

    Robyn Brickel, MA, LMFT   Robyn Brickel, MA, LMFT is the founder and director of Brickel and Associates, LLC in Old Town Alexandria, Virginia, which she established in 1999. Her insights for parent and teens appear in interviews in The Washington Post, and Washington Parent magazine, and she presents educational workshops for clinicians on the treatment of adolescent substance abuse and trauma. Her counseling and psychoeducational services provide treatment for recovery from trauma and/or abuse, including dissociation; addictions; adult children of alcoholics (ACOA) issues;

Editor:  Saad Shaheed


Prevalence and Statistics

Accurate statistics about self-harm are hard to find because so much goes unreported. Estimates vary widely; between 3% and 38% of adolescents and young adults report engaging in self-harming behavior, says the Refuge, a treatment resource.

What is Self-Harming Behavior?

Cutting is the most often recognized form of self-injury. But self-harm comes in many forms.  It is any self-injurious behavior that is harmful, that is used as a coping skill. Some specific examples include:

  • Cutting
  • Breaking bones intentionally
  • Piercing the skin with pins or other objects
  • Burning or scalding parts of the body
  • Pulling out hair, fingernails or pieces of skin
  • Banging the head, hands, feet, knees or limbs against hard surfaces
  • Slapping or punching oneself

It is natural to feel shock or disbelief when seeing self-injurious behavior.  It seems unbelievable to those unaware of the hidden emotional pain, how cutting into an arm or burning the skin could help anyone cope with overwhelming emotions.

It is important to see self-harm as a kind of meta communication around someone’s emotional pain. The behavior has meaning or value for the person doing it. That meaning or understanding is so important to move toward healing.

Why People Use Self-Harming Behavior

On the surface, self-harming behavior may look like a form of self-punishment.  It may be, but it also serves as a mechanism for emotional self-regulation for those with unresolved trauma. Survivors of trauma may injure the parts of themselves they feel ‘bad’ about. It’s as if those parts can be ‘punished,’ in an effort to cope with complex negative experiences, such as shame, within themselves.

Sometimes, clients report they use self-harming behavior as a distraction.  It hurts and that’s the intention.  The physical pain helps dissociate from the emotional pain that is overloading a person’s ability to cope.  The shift in attention helps them feel as if they are more emotionally regulated.

Unfortunately, the behavior can also consume the attention of those people who care about someone who self-harms.  It’s heartbreaking to watch a loved one using these behaviors. Family members may criticize or yell at them in desperation to stop them from acting in a way that seems senseless and dangerous.. Unfortunately, focusing on the behavior alone compounds the trauma, and keeps the deeper pain from being understood. That is why the therapist’s compassionate awareness is so important. It begins by understanding that those who self-harm are just doing the best they can to cope with a world that feels terrifying or overwhelming.

Tuning Into the Overwhelm Beneath the Behavior

As therapists, we recognize the importance of tuning into the emotional pain of someone who self-harms, rather than the behavior itself.  Parents may recognize the need to look deeper at the underlying turmoil.  Writer James Hunt describes coming to terms with his son Jude’s self-harming behavior after Jude was diagnosed with autism.

Around age 2, Jude began having meltdowns, and would slam his knees onto the hard floor or stomp his feet.  Later, he would use his hands, “slapping his arms, legs, and feet over and over until they were raw,” and even slapping and punching his face.

“I’d do anything to help him relax and stop hitting himself,” Hunt explains.  “I’ve gotten angry with him, I’ve shouted, cried, begged him to stop. ” But over the years, Hunt came to accept that autism was part of Jude’s life, part of his struggle with sensory overload.

Now Jude is 7, and self-harms less often. His father sees himself responding better when it does happen: “I’m calm and I do my best to reduce or remove whatever stresses are overwhelming him at the moment.  I know the best way to help him calm down.  I’m more in tune with what may cause a sensory overload for him and try to prevent him from being exposed to it as much as I can.”

Working With the Person Who Self-Harms and With Their Loved Ones

Treating self-harm means bringing a compassionate, self-caring attitude to the behavior.

The person is using the behavior to cope with anxiety or emotional pain that is outside their window of tolerance of emotions.  Physical pain has become their way to calm emotional pain; either overwhelming hyper-arousal or numbing hypo-arousal, which feels unsafe and unstable.

In therapy, stabilization is our first goal. We set up a compassionate, understanding relationship that acknowledges their emotional pain and assures them they are not alone in facing it.  They can feel sure they are not going to be judged or shamed for it.

In therapy, we work on grounding, or stabilizing by bringing awareness back into the present moment and the body they live in. As a therapist, I might use a variety of approaches to help the client feel more grounded in the present.  For example, we might use verbal ones, such as noticing things in the room that correlate to the senses, such as what do you hear, see, smell, etc.

At times I may use more physical or sensorimotor/somatic exercises, like tossing a pillow back and forth to help a client bring their awareness back to the current moment if they get triggered or dissociate. I may ask the client to talk about what’s going on for them. How do they notice being in the room with me? How are they noticing their emotions?

Lisa Ferentz’s self-care technique called CARESS (for communicate alternatively, release endorphins, and self-soothe) is a great teaching tool to help clients with self-regulation. See More Resources below for additional information.

In later phases of treatment, we will process their trauma history and the feelings that are associated with what happened during experiences that led to unbearable stress. A trauma-Informed approach is so important here, to avoid re-traumatizing the client. Trauma-informed therapists know that naming all of the details of their trauma is not necessary for healing.

But at the start, it is most important to help the person feel safe enough to start listening to their body, and become open to learning ways to self-soothe without using self-harming behavior.

The Importance of Self-Care in Recovery from Self-Harming Behavior

In therapy, I teach both clients and loved ones about taking care of wounds that happen because of self-injuring behavior. We guide children and adolescents to show injuries to a parent or primary caregiver. We help parents or loved ones support their loved one in treating the injury so it heals well, and to evaluate whether any cuts or wounds needs stitches or other medical care.

Safety also means making sure injuries do not get infected or that people who use self-harm do not unintentionally endanger their lives.  Self-harming behavior is not usually a suicidal act.  The loved one’s role in wound care allows the person who self-harms to experience acceptance of what they feel, and to feel cared about. Attention and understanding from a loved one can help reduce the risk of accidental death or more serious harm.

Compassion for Parents and Partners of Those who Self-Harm

Therapy for self-harming behavior means having a lot of compassion for the parents or partners as well.  The parents and loved ones are trying their hardest to help but they don’t always know what to do.

Many parents and loved ones attempt to control their own hyper-aroused anxiety by hiding everything and anything the self-harming person might use.  It is natural to want to control the outward mechanism their loved one is using to cope, especially when it’s dangerous to life.  Safety is of course, the most important thing. That said, we want to help loved ones focus on helping to heal the underlying pain.

Healing Conversations

It’s difficult to be compassionate if you don’t yet understand the person’s struggle to manage their emotions. Yet it is possible — and healing — to circle back to an initial reaction that may have temporarily made things worse (e.g., “Are you crazy? What did you DO?”).

Parents and loved ones can help the healing process by returning with new compassion to that moment:  “I’m so sorry I was taken by surprise. I just want you to know that I love you and I understand that there’s something going on for you.”

If you love someone who uses self-harming behavior, it’s okay if you don’t get it right the first time. You can bring healing and repair by noticing the alarm in yourself and taking care of calming it. Showing another how to self-soothe in a healthy way is a gift especially when their emotions are so overwhelming.

Self-care helps trauma survivors discover how to calm themselves and find healthier relationships. Far from being selfish in a negative way, self-care helps trauma survivors let go of behaviors that don’t serve them well, and take part in healing both internal relationships with themselves and externally with others.

In time, the regulation that they once tried to find through self-harm, they can now find in healthy connections, and good self-care.