Evaluating teen self-injury: Comorbidities and suicide risk
Improved affect modulation, coping skills can help teens stop harming themselves.
Address the parents’ concerns. During your assessment, also focus on the adolescent’s parents. They often are highly distressed, confused, and angry. They typically learn about the SIB from their child’s school counselors or peers and feel betrayed and guilty. They may want to be excessively intrusive and punitive and need support, information, and guidance to address their child’s safety.
Table 2
SIB: Spotting behavioral clues
Adolescents
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Parents
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Treatment recommendations
Always take SIB in adolescents seriously, and not as something they will “outgrow.” Adolescents with SIB need help modulating affect, stabilizing interpersonal relationships, and developing more adaptive coping strategies and problem-solving skills. Underlying dynamics—especially childhood trauma—must be explored and resolved.
Few evidence-based studies have evaluated SIB treatment in adolescents. Clinicians have extrapolated suggested interventions from the adult literature; however, much of this data was obtained from treating adult women with borderline personality disorder.
No medications are FDA-approved for treating SIB. Use pharmacologic interventions to treat underlying disorders, such as depression or anxiety, so that patients are better able to participate in other therapeutic interventions.
Dialectical behavioral therapy (DBT) is the only therapeutic entity shown in controlled trials to successfully treat SIB. Weekly individual psychotherapy and skills training groups focus on:
- regulating emotions
- tolerating distress
- improving interpersonal relationships
- reducing identity confusion and maladaptive cognitions.9
Substitute behaviors. The treatment goal is for patients to substitute less destructive behaviors in response to intense emotional states. Some can use techniques such as snapping a rubber band or rubbing ice against the skin, both of which cause discomfort without injury. Patients can listen to music, create art, write in journals, or engage in other physical activities. Each patient has to find a different behavior that works.
Prevention. Although SIB can be done with any object, most adolescents have a preferred method for causing self-injury and may have a “kit” of equipment. Identify and remove any tools the adolescent uses for self-injury. Because SIB is a highly ritualistic behavior, denying access to the preferred tools can help reduce self-injury frequency and convey that the behavior is unacceptable.
One individual should be designated to monitor the adolescent for SIB. Adolescents are seeking trust and do not respond well to constant questions about their behavior. Because some parents can become intrusive, monitoring may be best assigned to the adolescent’s therapist or a less emotional parent.
CASE 3: Scars provoke relapse
Claudia, a musically talented teen with SIB, withdraws from her choir when they choose costumes with short sleeves. She had not engaged in SIB in >1 year but has scarring and cheloid from the cuts. Years later she starts cutting again after laser treatments fail to remove the scars. She is frustrated because she will always have to wear long sleeves.
Treatment is essential, however, because this behavior can last for decades and leave scars that might interfere with future goals. The longer the adolescent has been dependent on the behavior, the more difficult it is to treat.
Related resources
- Levenkron S. Cutting: understanding and overcoming self-mutilation. New York: W.W. Norton & Company; 1998.
- Favazza AR. Bodies under siege: self-mutilation and body modification in culture and psychiatry. 2nd ed. Baltimore: The Johns Hopkins University Press; 1996.
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
