Me – “What does depression get you doing that is against your better judgment?”
Teenage client – “Cut.”
Self-harm is a phenomenon that is becoming more and more prevalent among adolescents and teens. It has many ways of presenting itself – cutting, burning, bruising, branding, scraping, piercing (not the tattoo/piercing parlor type), head banging, scratching, unsafe sex, risky drinking and even breaking bones to name a few.
Parents often call me desperately looking for information and answers to “I’m really scared and worried. What can I do?” The terror is palpable over the phone and evokes in me a desire to somehow wrap comfort around these parents. However, I am often placed in the position of telling these parents I do not have the freedom to share information with them about their teens’ sessions with me and end the conversation by making some generic suggestions. Then I put down the phone; put my head in my hands, pause, and take a couple of deep breaths.
Those of you who are parents – take a breath and then keep reading. This post is for you. It is especially for those parents who are banned from therapy sessions with their teenager because your child has requested complete confidentiality – including confidentiality from you.
I want you to have some answers. I want you to have access to accurate information and some clear direction. I want you to know how I am working to help your child – what’s happening behind the closed door.
The following is some information I would tell you if I had the time and permission – because it’s generic, I can and in greater depth. To simplify it, I’ve organized it all in question/answer format.
Can my child really request their sessions remain confidential – even from me?
Yes. If your child has reached the age of 14 in the State of Pennsylvania, their confidentiality is protected by law – which means that therapists are also bound by law. (This age may be different in your state – please check.)
Confidentiality is an important aspect of therapy, especially for children who don’t feel they have any place to put those things which are most important to them. Assuring their confidentiality (even from their caregivers) can be encouraging to them in sharing their deepest hurts and feelings about what is going on in their lives. Therapy becomes a safe and trustworthy place with the opportunity to be heard without judgment. Safety is lost the more you express your worry and anxiety through prying.
However, the laws of disclosure still apply in this situation. A therapist has an obligation to report to you, and other authorities if necessary, if they suspect your child is a danger to themself or to someone else. If the therapist has a serious concern, they will let you know.
Why on earth would a child do such a thing?
“…the boy [who was self-harming by chewing on the buds of cacti, causing profuse bleeding]…pointed to his mouth, and said flatly, ‘The pain here is nothing compared to the pain here,’ this time pointing to his heart.” (Selekman, 2007, p. vii)
By being able to feel physical pain, the internal emotional pain is muted. Kids tend to use self-harm as a tool to help them feel better on the inside, gain some control over a life that feels out of control or is a desperate attempt to feel something (as opposed to a “black hole”). In a way, this is hopeful. It is a clear statement of their desire to be free of emotional pain by feeling physical pain, but not free of all feeling. I would rather your child want to feel something over not wanting to feel anything at all.
Isn’t this something you only see in girls?
Self-harm is an equal opportunity behavior – it is equally practiced by both males and females. It also is present across age groups and socio-economic status. The only stark difference is the rates of self-harm seem to be slightly lower in Asian and Asian-American populations. Why? There’s no clear answer for this.
Is self-harm really as prevalent as you’re suggesting?
Yes, it is. But, it has been difficult to get accurate numbers given the secrecy associated with self-harm. The conservative estimates are that self-injury is at about 15% among the adolescent population. The number is probably higher because in an anonymous survey, 17% of college students reported they self-harm. Unfortunately, it looks like the numbers are rising.
Why my child?
This is a hard one. There can be all kinds of reasons leading to what many kids who self-harm report as feeling they really don’t have anyone they can talk to who accepts them for who they are. Here are some possible risk factors:
- A history of sexual and/or emotional abuse
- Low self-esteem
- Childhood neglect
- Social isolation
- Unstable living conditions
- Families that suppress and cannot tolerate unpleasant emotions
- A history of or current struggle with mental health issues (eating disorders, depression, anxiety, obsessive compulsive disorder, post-traumatic-stress disorder)
- Family history of suicide
- Families where feelings are disregarded or diminished; there’s no-one who understands the feelings and inner life of the child
What do you mean by “families that suppress and cannot tolerate unpleasant emotions”?
The ability to tolerate unpleasant emotions and the related skills of problems solving, active listening, communicating, identifying emotions and their potential source are all necessary for healthy relationships. When these skills are missing, there is no place to put all the “bad stuff” in our lives and no way to resolve them.
Part of our jobs as parents is to be able to pass along the skills of living and relating to our children. But, the only way we can do this is to have these skills ourselves. We cannot pass along what we don’t know. Families of self-harming kids may not have these necessary skills not because they don’t love their children but, because they never learned how.
Is my child suicidal?
Not all self-harming adolescents and teens are suicidal. In fact, as many as 60% of them have never had suicidal thoughts. But, self-harm can be a harbinger of suicidal ideation (the state of having suicidal thoughts and plans). The danger in self-cutting is that it can lead to accidental suicide.
Why don’t these kids just stop self-harming?
It’s not as easy as that. The ease of giving up self-harming behavior is dependent on how long it has been going on. It’s easier to think of self-harm along the same lines of drug abuse and addiction.
Initially, cutting can be experimental – something that kids have heard will ease the pain. When self-harm occurs, experts theorize opioid-like endorphins are released in the brain which creates a natural high and emotional relief. The more often kids engage in self-harm, the greater the chance there is of an “addiction” to the behavior. The greater the addiction, the more difficult it is to treat because self-harm has its own form of cravings and withdrawal.
Some kids don’t stop because they can’t.
The sooner self-harm is identified and treated, the faster it will end, hopefully without leaving lasting scars – both emotionally and physically.
What does treatment look like?
Self-harm is a behavior that is very difficult to treat. Therefore, it is important to get your child into therapy with someone who has experience working with self-harming behaviors. ASAP.
The first step is to get some safety and containment around the behavior. This is the most difficult part for parents. Because “stop” is a process, therapists will normally start with educating your child on how to stay safe if they self-harm with the goal to decreasing the behavior.
For example, in the case of cutting, they may encourage your child to make sure they take care of their wounds to avoid infections as well as alert teens to signs they may have gone too far and need medical attention. As a parent, restrict access to sharp implements, but kids have been known to find creative ways of being able to continue in this behavior. Therefore, make sure your child knows where all the medical supplies are in your home while also expressing your hope they will find other ways to address their pain and your love for them. Also let them know that you are there to talk to them. When they do come to you, listen non-judgmentally and with the aim of understanding them to the point where they feel understood. There is a stark difference between thinking you understand your child and your child feeling that you have understood them. You are aiming for the latter.
Treatment can take the form of individual sessions and family sessions. I personally encourage parents to get their own therapist to learn how to cope with their own fear and anxiety, get information about what self-harming is all about, learn solid communications skills and begin the discipline of being non–judgmental. During intake, the therapist will ascertain what other issues may be important to discuss with you based on your personal history individually and, if applicable, as a couple and family.
Individual treatment with your child generally focuses on managing any urges that may arise during the course of treatment, helping them better tolerate stress, regulate their emotions, improve their relationships, and providing self-care and self-soothing skills they can use to cope with their emotions. Throughout this process, there is a gentle nudging in the hope of encouraging communication with parents and movement towards engaging in family therapy.
Are there any medications that treat self-injury?
But, it may be helpful to medicate possible underlying emotional issues such as depression and anxiety. However, this is a conversation to have with a psychiatrist or your child’s doctor. Specifically ask about the “black box” warning on antidepressants – it contains important information on how these drugs may affect your child. Make sure to ask about long term studies on children, the pros and cons of medication and adverse reactions so you and your child can make an informed decision.
This is a lot to digest and I probably haven’t covered everything.
Feel free to send me a message – personally or through this blog – if you have any other questions.
…and don’t forget to breathe.