What Every Parent Needs to Know About Self-Injury. Tonja Krautter
It was at that very moment she knew she would self-injure again despite the fact that she knew what she was doing was wrong. The good feelings self-injury gave her outweighed the guilt and shame she experienced during and after the act of self-harm.
Understanding Self-Injury
“I have been battling with self-injury for three years now, but you would never know it by just looking at me. I have been better, and I have definitely been worse, but one thing that is always the same is my scars. They are daily reminders of the places I have been and where I hope to never go again. But they are also an open door for people to see and to try to understand.” - Rebecca, age 16
Self-injury is a complex phenomenon that frightens and confuses most parents. It seems incomprehensible that a child would take a knife, razor blade, lighter or fist and intentionally harm herself. Parents do not understand what their child is trying to achieve. They only know that their child is engaging in a behavior that is self-destructive. It is painful for parents to watch, especially because they feel helpless to stop the behavior.
There are a variety of different factors and reasons that lead to the onset and maintenance of this problem. Accordingly, helping a child recover from this problem must start with a thorough examination of the problem itself. It is my hope that this chapter will help parents gain the understanding, knowledge, and insight necessary to support their child through treatment and recovery.
Self-Injury vs. Suicide
Self-injury is a coping mechanism. In contrast to what most people think, it is not a suicide attempt. In fact, the majority of self-injurers report that they engage in this behavior in an attempt to avoid suicidal ideation or action. The goal of self-injurious behavior is generally to feel better, not to end life. However, that does not mean that self-injury cannot unintentionally lead to death. If the person’s behavior falls into a high-risk category (see below), it is possible that she may die unintentionally from self-harm.
For example, years ago I supervised interns who worked on a crisis hotline. One anonymous caller phoned in to talk about her severe depression. The caller denied any suicidal thoughts or intent. However, she did admit to a history of self-injurious behavior. At my request, the intern asked the caller if she was currently engaging in self-harm. The caller admitted that she was, and indicated that the cuts she was currently making on her inner thigh were bleeding heavily. Under direction from the intern, the caller was able to tell someone in her home about the injuries and was immediately rushed to the hospital. She received 78 stitches in her leg. The doctor reported that, although she may not have been trying to kill herself, she almost did.
Another factor to consider when evaluating self-injurious behavior versus suicidal intent is that both may be present at the same time. In other words, it is possible that the person engaging in self-injury is also actively suicidal. If this is the case, then their self-injurious behavior may in fact become a suicide attempt(s). Since some self-injurers are suicidal and some are not, it is very important to ask the person who is harming herself if she is having any thoughts about death and dying. If she is, further questioning is imperative. It is important to find out if she is actively thinking about killing herself and, if so, whether she has a plan in place to die.
If your child reports suicidal ideation especially with a plan in place, she must be taken immediately to the nearest emergency room for a more thorough safety assessment. Some parents are uncomfortable asking their children questions around suicide. The biggest fear is often that if they bring up the subject, their child who was not feeling suicidal will suddenly begin to think about killing herself. This is almost never the case. Think about yourself. If you are mentally stable and happy in your life and a friend comes up to you and asks if you are suicidal, would you all of a sudden start thinking about killing yourself? I always tell parents not to be afraid to ask the tough questions. If, to your knowledge, your child was not suicidal before and your questions reveal suicidal ideation, you may have just saved her life.
If you do not want to ask your child these types of questions for whatever reason, do not worry. There are several types of mental health professionals who will cover this topic as part of a thorough assessment. If you are worried about your child’s safety, you can bring her to a therapist for this type of assessment. If she is unwilling to talk to a therapist in an office, you can contact an adolescent crisis mobile unit (most counties have them). These mobile units are staffed by trained mental health professionals 24 hours a day, 7 days per week, and can travel to your location. They will come out to schools, homes, and even to parks, malls, or parking lots. If the crisis unit determines that the individual is at high risk for harm, they will transport the individual to the hospital. Usually the goal is to try to keep the person out of the hospital by arranging crisis counseling and implementing a safety plan at home. However, this is not always an option.
Once at the hospital, usually a psychiatric nurse or crisis intervention specialist evaluates the safety risk. If it is high, then the hospital staff will hold the individual as a safety precaution and treatment intervention. The hospital staff will refer to this as a “72-hour hold” or a “5150” (California Welfare and Institution Code, Section 5150). An individual is held for 72 hours so that she can be assessed for continued safety risk or suicidal ideation/intent. If, after 72 hours, the individual is assessed to be safe (no longer a risk to herself or others) then she is released. If her safety status has not changed (still at risk for harming herself), then she will be placed on another hold called a “5250.” This process continues as long as the person is in danger of harming herself. It is likely that the individual will be transported and admitted to a psychiatric hospital before beginning her 72 hour hold. These hospitals have trained professionals to work with adolescents in crisis.
It is important for parents to help their child understand that being held in the hospital is not a form of punishment. Insinuating that it is a punishment often worsens their negative feelings about themselves and heightens the risk of self-injury. It should be clear that the hospital stay is a temporary treatment intervention focused on safety. It should be viewed as a loving, caring, and supportive environment for a person who is suffering.
Along the same lines, parents should never threaten to send their child to a hospital for “misbehaving.” These threats are problematic for a few reasons. First, they create the impression that the hospital is a place of punishment. Second, a person will never be admitted to a hospital for misbehaving. The requirements for admittance are very specific and clear. A person will be admitted if they are at suicidal, homicidal or gravely disabled (meaning due to a mental disorder, the person cannot take care of even her own personal basic needs, i.e, food, clothing, shelter). Third, and perhaps most importantly, these kinds of threats make a child feel like they are a burden, and that their parents are trying to get rid of them. This leads to feelings of shame, guilt, hopelessness, and overwhelming sadness.
Sara was 13 years old when her mother asked her if she was suicidal. Her parents were aware of their daughter’s self-injurious past. Sara used to scratch her arms a few times a week when she was stressed out. This went on for approximately three months before she entered treatment. More recently, Sara’s parents noticed that she had fresh cuts on her shins. Sara told them that she fell walking up a flight of stairs at school. Her parents wanted to believe her since, to their knowledge, she had not harmed herself in over six months. However, something was different about their daughter this time. Sara was not eating or sleeping well. She was isolating herself from her friends and she was irritable with all family members. In the past, even when Sara engaged in self-injurious behavior, she seemed happy. In fact, her parents had no idea she was cutting herself until they got a call from her teacher. This time Sara’s mood was different. She seemed deeply depressed and her mother was certain that something was very wrong.
At first, Sara denied having any suicidal ideation. She told her mother that she was “in a bad mood” and asked to be left alone. Her mother was not convinced by her denial of suicidal feelings and re-approached her. She knew that self-injury was typically not an indicator of suicidal intent, but she also knew that her daughter could be self-injuring and suicidal at the same time.
Sara’s mother followed her instincts. She told