Joan Goodman- LCSW-C, BCD

After thirty six years in private psychotherapy practice, specializing in the treatment of adolescents, I have grown to view my clinical practice as a microcosm of the adolescent world. The behavior of adolescent self-injury is one such condition that appeared in my office in the spring of 1996.

     I was first referred a few teenagers who hurt themselves. I never experienced adolescent self injury before and it seemed like a small trickle of new clients –perhaps a reflecting a new fad. I recognized early that it was important not to concentrate on the image of the teen’s act of “self harm” in order to proceed. I knew enough to never tell a teenager to just STOP, because that instantly creates a control battle, causing the teen to want to do it more. One never wins a control battle with a teenager! Over the years,  the trickle became a tidal wave and a major part of my practice.. I developed theories, fine tuned approaches and designed ground breaking techniques to effectively treat this condition.

     Adolescent self injury is an extremely complicated behavior that often serves many functions simultaneously. It has different meanings for each teenager. What makes this behavior even more difficult to treat is the denial of its seriousness, along with built-in resistance that can often accompany it. Many teens see nothing wrong with it--in fact, they like it.  It becomes a form of self-medication.  This is because the brain releases endorphins when someone is extremely stressed and self-injures. Like rigorous exercise, it can produce a sense of rapid relief.  These teens do not want to stop. Self injury becomes addictive once it becomes repetitive. 

     For this reason, it is important to slowly help the teenager find some place in their thinking where the idea of self injury is “not ok.” Being able to develop that place is the challenge. I have spent more than three decades working with teenagers to develop that place. Once there, the teen can see self injury as a problem, not an achievement.

     Many of these teenagers are perfectionists. They appear to have it all together.  They get all A’s, take advanced classes, always smile and feel the need to prove that they can do everything. Because they are supposed to be perfect, they cannot reach out for help. This is the same profile of a teenager with anorexia, no one should be surprised if the self-injury stops but an eating disorder surfaces. Both conditions give the teenager a feeling of control when life feels out of control.

     Teenagers often use self-injury as a distraction from their painful emotional life. Feeling physical pain is easier than feeling emotional pain. One 16 year old girl explained, “if you have a toothache, have someone stomp on your foot". A 13 year old girl confided in me that cutting was easier than feeling her emotional pain--she  had control of when, how hard, or how long she hurt herself; whereas she had no control over how she feels emotionally. Additionally, cleaning and bandaging the wound created a sense of well-being for the young teenager--it distracted her from the issue that triggered the self-injury. Each injury is a cry for help because they cannot cope with their painful emotions.

     Physical wounds serve as evidence to these teens and the world that their pain is real. If their wound can’t be seen or touched, their emotional pain does not exist. One 14 year old needed to see her own blood to be able to “get the bad parts out”. Another teen needed to see, feel and sometimes taste her own blood in order to believe her pain was real.

     Self Injury can start out as simply as scratching one’s arm, or by removing the small eraser at the end of a # 2 pencil, and pushing the round metal piece together to then be used as a sharp instrument. This can lead to using a razor, a kitchen knife, or an exacto-knife. Or, one can easily break a light bulb for sharp pieces of glass. Self-injury becomes addictive when it becomes repetitive. It can then seem to develop a life of its own.   The most common form of self-injury is cutting or burning oneself.   Other forms of self injury include: hair pulling, face picking, self-hitting, head banging, severe skin scratching, bone breaking, or interfering with wound healing.

     Common warning signs of adolescents who self-injure include: wearing long sleeves /pants all the time (even in hot weather), avoiding exposure of certain areas or demanding complete privacy when getting undressed, refusal to wear shorts, short sleeves, sleeveless shirts, or bathing suit even on warm days, wearing a wrist warmer (to cover scars on wrists), unexplained bruises, cuts, bandages, and frequent accidents followed by flimsy excuses.

      In the cases where the parents have discovered that the teenager is self-injuring, but the teenager denies it; the teen is usually referred to an adolescent pediatrician where any scars would be discovered during a physical exam. Since self-injury is the teen’s way to manage either depression or mood swings, a psychiatric medication evaluation should be part of the evaluation process.