I noticed Sarah’s arms as soon as I met her. It is hard not to, as 15 years of self-injury have rendered them more scar than skin. Sarah isn’t my student, but I’ve taught plenty of kids like her, and she offered to talk to me about why she has cut herself for a decade and a half, and how the adults in her life could have helped her manage the pain that prompted her to self-injure.
By the time she first cut herself at 12, she’d already endured seven years of abuse at the hands of a parent. “Cutting was my comfort, from the very beginning. I know that sounds strange — to cause pain to feel better — but it worked. Sometimes, if I was feeling anxious in school, all I had to do was go in to the bathroom and look at my scars. Just seeing them comforted me.”
It can be difficult for people who have never sought relief through self-injury to understand Sarah’s actions, but to Dr. Michael Hollander, director of Training and Consultations on the 3East Dialectical Behavioral Therapy program at McLean Hospital in Belmont, Mass., and author of “Helping Teens Who Cut: Understanding and Ending Self-Injury,” her explanation makes sense.
In Sarah’s mind, self-injury functions as an effective, albeit destructive and dangerous, coping mechanism. “The vast majority of kids who cut themselves do so as an emotion-regulation strategy, and, unfortunately, it works, which is why it’s so hard to get them to stop,” Dr. Hollander said.
Kids who cut themselves are either jumping out of their skin and use self-injury to calm themselves down, or are numb and empty and use self-injury to feel something. A small percentage use it for avoidance, to create a distraction, and an even smaller percentage use it to get attention. Some, a very small group of kids, use it to punish themselves; kids who feel they don’t deserve to live, breathe or take up space may cut themselves, usually in the context of an extreme emotional situation.
Kids who self-injure tend to be particularly emotionally sensitive and vulnerable and suffer from what Dr. Hollander calls “emotional illiteracy.” They can’t name their feelings, let alone formulate a plan for managing and coping with them. Strategies that work with most kids, such as reassurance, minimizing the severity of difficulties, or offering to help them solve problems, can backfire with kids who self-injure.
When I asked Dr. Hollander to offer ways teachers and parents can help kids who self-injure, he said that what adults should not do is often more important than what they should.
Do not agree to confidentiality. “All too often, well-meaning adults agree to keep the self-injury a secret on the promise that the kid won’t do it again, and this is a terrible idea.” While cutting is not generally a suicide attempt, “there’s a link between cutting and suicide. Suicide risk is nine times higher if there’s a history of self-injurious behavior, and some believe that self-injury is a sort of rehearsal for more severe injuries that can lead to death.”
Adults should not prioritize relationships with a child above that child’s well-being. “Kids who self-harm need treatment, and in short order,” Dr. Hollander stressed. Giving in to their pleas for more time, silence or additional counsel only delays treatment and could lead to further, more serious injury.
Do not suggest substitute behaviors for self-injury. Offering such advice, Dr. Hollander explains, can slide into the territory of treatment, and laypeople are not qualified to counsel or treat kids who self-injure, no matter how many books and articles they read.
What adults should do, according to Dr. Hollander, is validate children’s feelings, and work with the family or social services to get that child into treatment as quickly as possible.
Validation, Dr. Hollander stresses in his book, is the key to supporting a child who self-injures. “To validate someone is to communicate that you understand other person’s experience. You don’t have to like to or agree with it; you just have to acknowledge it.” Solving their problems, attempting to put their emotional pain in perspective, reassuring, and offering “I’ve been there” feedback may feel helpful in the moment, but when emotions feel overwhelming, and an adult tells you that everything is going to be O.K., emotionally sensitive kids can hear that reassurance as an invalidation of their feelings.
Above all else, initiate professional treatment. Self-injury that goes untreated can evolve from minor cuts to life-threatening injuries in a moment. As Sarah explained, her worst injuries always began as tiny cuts, “just a scratch, maybe one that would look like the cat did it,” and ended in a trip to the emergency room. “Because I am disconnected from my body and physical pain when I cut myself, it’s the sight of the blood — not the pain — that brings me back to myself, and things can get out of control pretty fast.”
As we finished talking, I pointed to the marks highest up on her forearm, scars that seemed to form words.
“What does that say?” I asked.
“Part of it, down at the bottom, says ‘HELP ME,’ ” she replied.
She then pointed to a faded ‘I’, an ‘M’ and an ‘S’, and said, “That used to say ‘I’m sorry.’ I cut that just after I reported my dad to Child Protective Services.”
She slid her finger to the right, then tapped the clear ‘N’ she’d incised next to the “I’m” and added, in a half-smile, “I added the ‘Not’ later.”
She shrugged, took a deep breath, and stretched her sleeves down over her fingertips to let me know that our interview was over.