SELF-HARM

7/29/2023 Self-Harm
A quest to comfort

Dr. Priyanka Halwasiya and Ms. Shreya Singhal

PEDIATRIC PSYCHIATRIC SERVICES, SIR GANGA RAM HOSPITAL

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What is Self-Harm? ___________________________________________________________________________________ 1

Types ________________________________________________________________________________________________________ 2

How may you know that a child/adolescent is hurting? ___________________________________________ 2

Why Self-Harm? _______________________________________________________________________________________ 2

Let’s Remove the Stigma _____________________________________________________________________________ 3

SELF-HARM IS ATTENTION SEEKING __________________________________________________________________ 3

SELF-HARM IS A TEENAGE MODERN PROBLEM ______________________________________________________ 3

PEOPLE WHO SELF-INJURE ARE CRAZY AND/OR DANGEROUS ___________________________________ 3

SELF-HARM IS AN ATTEMPT TO SUICIDE _____________________________________________________________ 3

SELF-HARM IS A CHOICE _________________________________________________________________________________ 3

ONLY GIRLS SELF-HARM _________________________________________________________________________________ 4

Looking Beyond The Act _____________________________________________________________________________ 4

Ways To Support ______________________________________________________________________________________ 4

IDENTIFICATION AND APPROACHING THE STUDENT ______________________________________________ 4

In Case of Emergency Situation: ____________________________________________________________________ 6

STRATEGIES TO MANAGE URGES TO SELF-HARM________________________________________________ 7

Additional Resources _________________________________________________________________________________ 9

What is Self-Harm?
Self-harm, as per the National Institute for Health and Care Excellence (2018) is defined as an
act of self-poisoning or injury, irrespective of its purpose. It is an expression of personal distress
and should not be viewed as an illness and can be carried out for various apparent or
unapparent reasons.

Self-harm can be perceived as a red flag to indicate inner distress and turmoil that needs to be
addressed. It is an act of hurting yourself and is governed by an urge to harm self to deal with
disturbing thoughts, feelings and events.

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Recent statistics as per a qualitative study published in (2022), it was found that about 6.8% of
students below the age of 13 engage in self-harm, in Australia.

Types
Self-harm can affect people of any age, social status, gender identity, sexuality, race or culture.
However, when talking about self-harm, the first thing that comes to mind is cutting oneself,
though physical self-harm may or may not be visible as any external sign of wound or mark,
and can include the following-

o Self-cutting o Pulling out hair

o Taking an overdose o Scratching or picking sores on skin
o Hitting or bruising o Swallowing objects
o Burning o Poisoning
o Hanging o Banging
o Suffocation o healing prevention
o head banging o pinching

How may you know that a child/adolescent is hurting?

➔ Unexplained cuts, burns or bruises.
➔ Withdrawal or isolation from friends and family
➔ Wearing clothing inappropriate for the weather, such as long sleeves or pants in hot
weather to be fully covered or avoiding activities that may require a dress code such as
swimming.
➔ Low mood and lack of interest
➔ Blaming oneself for problems, expression of feelings of failure, anger, hopelessness or
worthlessness
➔ Spending long periods of time alone, particularly in the bathroom

Why Self-Harm?
Self-harm is an isolating experience since people around including family, friends, mentors or
medical professionals may not be able to understand the “whys” of the act or need to hurt self.
It may or may not be an attempt to suicide, and rather may at times be an act of survival. Self-
harm is a way for children and teens:

● To manage and/or express overwhelming emotions

● To release emotional distress
● To prevent suicidal thoughts from overpowering
● Use it as a form of punishment to self
● To deal with emotional or physical numbness i.e., to be able to feel something and alive.
● To feel in control/empowered
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● To ask for help
● To interrupt intrusive thoughts
● Using it as a diversion and being able to express all of one's feelings through a single act

By the way of harming oneself, the person is seeking help, an outlet for a lot of unsaid/said
emotions which are bothering them.

Let’s Remove the Stigma

Social labels such as ‘attention-seekers’, ‘weak’, ‘mad’, or ‘silly’ are often used for people
affected by self-harm. It can lead to unreported incidents and increase risk to child/adolescent.

SELF-HARM IS ATTENTION SEEKING

Self-harm reflects that emotional pain or experiences have become unbearable. It is not
done with a purpose to gain attention rather it is the underlying distress behind the act
that deserves attention. In fact, most attempts of self-harm are done in private and are
kept a secret. Terming people as ‘attention-seekers’ and making assumptions about
‘seeking attention’ can lead to secondary distress, leading to further self-harm.

SELF-HARM IS A TEENAGE MODERN PROBLEM

Self-harm is a long-lasting experience and can affect people of all ages. It is not limited
to teenagers and does not stop after teenage years.

PEOPLE WHO SELF-INJURE ARE CRAZY AND/OR DANGEROUS

Although many people who self-harm are suffering from disorders such as eating
disorders, anxiety or depression, they aren’t crazy or dangerous. Self-harm provides
them as a means to cope when the emotional distress seems to be unbearable.

SELF-HARM IS AN ATTEMPT TO SUICIDE

While there can be overlaps between attempt to suicide and self-harm, self-harm is
often an act to avoid suicide. However, people who have a long history of self-harming
and who have attempted self-harm in the past 12 months, are often at a greater risk of
suicide.

SELF-HARM IS A CHOICE
Self-harm is carried as a last resort after long periods of struggling with emotional
distress or depression and is not a simple first choice. Rather it seems to be the only
choice available.

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ONLY GIRLS SELF-HARM

It is often assumed that girls are more likely to engage in self-harm than boys. However,
in reality there is no such evidence, the two groups may engage in different self-harm
behaviors for different reasons.

Looking Beyond The Act

Episodes of self-harm are carried out to deal with intense emotional pain. It is not a mere act of
harming oneself. One needs to look beyond the act and understand the emotional state of the
individual which can lead them to use physical pain as a mode of escape and avoidance.

Every episode is different, many people use self-harm to utilize the intense physical pain to
override the more severe emotional pain, while others experience no physical pain as self-harm
allows them to dissociate from reality or space out.

Usually there is always an inherent message behind self-harm i.e. “I deserve this” or “I deserve
to be punished”. This message serves as a repeated reminder that pain is what one deserves
leading to repeated acts of self-harm.

In order to understand what goes beyond the act of self-harm it is important to understand the
Self-harm cycle. Self-harm starts as a way of relieving oneself from the build-up of emotional
distress. However as soon as this distress is relieved one experiences a temporary relief from
the psychological pain. However, such distressing feelings including shame and grief soon
follow again since it does not solve the root cause of the problem, and the cycle of self-harm
begins. Eventually, due to the temporary feelings of relief it can become someone’s normal way
of dealing with distress, making the cycle difficult to break.

Ways To Support
Schools play an important role when dealing with self-harm since a student spends a significant
portion of their time in schools. The importance of support from school becomes even more
important when there is a lack of support from parents, or the home environment isn’t
emotionally nurturing.

The following consists of the ways through which identification and subsequent support can be
provided inside school settings:

IDENTIFICATION AND APPROACHING THE STUDENT

Teachers and other important staff such as school nurses or first aid staff should be educated
about the signs and symptoms of self-harm and indications of a self-inflicted surgery, in order
to make appropriate identification.

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After the school's staff or a teacher has observed the signs and symptoms of self-harm in a
student the second step is to approach him/her. In order to approach them one should
communicate with them in an empathetic, caring, calm, understanding and non-judgmental
way. Interrogation can be direct or indirect depending upon the state of the student or degree
of concerns about self-harm. For example-

Indirect question: “I’ve noticed that you are becoming withdrawn, and I am wondering if
maybe things are difficult for you at the moment?”

Direct question: (used when there are explicit concerns)- “I’ve also noticed that you’ve got
some scars and I know that sometimes this can be a sign that someone has harmed
themselves. Can I ask if you’ve self-harmed?”

One should also keep in mind punishing the child or making them guilty/responsible for self-
harm is ineffective. Additionally, simply telling them not to self-harm is also unhelpful. It should
also be noted that one should not pressurize the student to talk about the details they aren’t
ready to talk about and provide them with a space to pace discussion.

Next is to follow up on those questions and try to understand the underlying reasons. In order
to know this one should have an understanding of some reasons why an individual engages in
self-harm, so that reasons can be probed into effectively and in an empathetic manner.

Some of the examples could be:

1. “I wonder what are the sorts of things that make you feel like harming yourself?”
2. “I wonder if you’re using self-harm as a way of coping with something that is troubling
you?”
3. “Sometimes people self-harm as a way of managing strong and difficult feelings or
emotions. I’m wondering if that might be why you hurt yourself?”

Certain other skills include-

1. Active listening without interruptions

2. Giving them your undivided attention
3. Talk about how their feelings and acknowledge them rather than probing about the
specifics of the event.
4. Try not to act shocked or disgusted.
5. Provide them with reassurance and emotional support.
6. Try to use language that is familiar to the student.

It should also be understood that the school’s staff may experience a range of emotions in
response to self-harm (such as sadness, guilt, anger, disbelief or disgust). One should identify
these emotions in self and discuss these with colleagues or others to deal with the impact of
self-harm on self.

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In Case of Emergency Situation:

Immediate effects of self-harm can be managed by
1. First, one needs to manage the physical injuries by keeping calm and following with the
first aid. The school nurse can be called upon to assist and in case of serious physical
injuries or overdose emergency hospital services should be called.
2. The second step is to help the student. In order to do this the school shall identify a
member of the staff to whom the young person is willing and comfortable to speak. One
should here keep in mind that self-harm is a mode to communicate the underlying
distress which needs to be addressed by the staff member in an empathetic manner.
3. Third step then is to provide them with alternative ways to cope up and to put them in
touch with the school counselor or provide them with external sources of help (see
below for alternative ways and other helpful activities).

Plan The Course Of Action

In order to plan the course of action, one should first understand the circumstances leading to
self-harm and whether there is a higher or lower level of concern.

Higher level of concern may be indicated by the following:

➔ Low mood
➔ Change in behavior- withdrawn/isolated or disruptive/angry
➔ Expressing hopelessness
➔ Expressing worthlessness and self-hatred
➔ Lack of family support
➔ Expression of suicidal thoughts
➔ Previous attempts of self-harm
➔ Possibility of physical or sexual abuse
➔ Incidents of bullying
➔ Concerns related to sexual or gender identity.
➔ Drug or alcohol abuse
➔ Bereavement (especially recent loss)
➔ Low level of attendance

The plan of action in case of higher concerns might require the school to:

1. Inform the parents and having regular follow up meetings.

2. Get the student in touch with child and adolescent mental health professionals.
3. Educate the students peer group to provide additional support.
4. Keep the school nurse, counselor and other concerned authorities updated and ready for
emergency.
5. Continue to provide supportive listening.
6. Having a crisis telephone number available and easily accessible to students
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In case of lower risk of concerns the following steps can be taken-

1. Providing supportive listening and working out with the student to provide them
support.
2. Get them in touch with the school counselor and work out with them possible alternative
or emotional release techniques to reduce the urges (see below for the list).
3. Talk to the student whether the school can or cannot inform the parents.
4. Consider how stress at school can be reduced.

STRATEGIES TO MANAGE URGES TO SELF-HARM

➢ BUILD SUPPORT NETWORKS

❖ Identify the people to whom the student is close to and trusts or the one who can
provide support. These can include family, friends, teachers etc., and then decide
how to get the student in touch with them.
❖ Getting the student to join some clubs inside the school such as theater, robotics
etc., which encourages group activity and provides opportunities to develop
friendships.
❖ Educating students to identify distress and symptoms of self-harm in their peers.
This can also include encouraging them to report to authorities and skills about how
to support and approach their peers.
❖ The school can also look into creating peer support groups, by training the students
to talk and provide support to their peers.

The following techniques require one to identify their triggers and the consequences i.e., the
feelings experienced after self-harm so as to break the cycle of self-harm.

➢ DISTRACTION ACTIVITIES

Distraction activities help delay the self-harm and give them confidence that the urges
can decline even when one does not act on their thoughts. Choosing different ways to
deal can make the urges become less urgent and immediate. This also includes using a
5-minute rule i.e., waiting for 5-minutes when you feel the need to self-harm and then
then wait for another 5-minutes to see whether you can go on without hurting yourself.
Do it till the time the need is over.

Other techniques include:

1. Going for a walk

2. Creating something such as drawing, writing, music etc.
3. Going to a public place away from home
4. Watching T.V. or movie
5. Talking to a friend
6. Reading a book
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7. Dance
8. Make a list of things that make one happy
9. Writing down negative thoughts and feeling and them tearing the page or crumpling
it

It can also include self-soothing techniques such as:

○ Having a bubble bath

○ Stroking a cat or other animal
○ Going to park and experiencing nature
○ Listening to soothing music
○ Wrapping yourself in a blanket
○ Smelling candles, favorite perfume, or other pleasing fragrances
○ Rocking yourself gently
○ Choose an object in room and write a detailed description of it.

➢ COPING WITH SYMPTOMS OF PHYSICAL STRESS:

These include certain strategies that can help to manage extreme tensions in the body.
These include-
1. Clenching the ice cubes in the hand until they melt
2. Hitting a soft object such as a pillow
3. Placed breathing exercises
4. Physical and relaxation exercises such as progressive muscle relaxation, running,
dancing to music etc
5. Drawing on the skin with a red pain instead of harming or sketching a photo of
self and then cutting or tearing it
6. Using a punchbag
7. Stretching and squeezing a playdough to relieve tension

➢ DEALING WITH EMOTIONAL DIFFICULTIES OR DISTRESS:

These include strategies that can be used to release emotional distress through their
expression-
1. Keeping a journal/diary
2. Writing down your feelings
3. Writing a letter to self or other about one’s feelings (this need not be sent)
4. Talking to others about them
5. Going to field and the screaming
6. Venting it out by crying
7. Creating a hope box i.e., maintaining a box about some positive things about
themselves or about life such as consisting of photos, memories, compliments
etc., to help them feel better

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Additional Resources
Helplines
1. iCALL- 9152987821. https://icallhelpline.org/ (check activeness- last posted in 2022)
2. The Samaritans Mumbai- 918422984528, +91 84229 84528
3. Jeevan Aastha Helpline- 1800 233 3330
4. Kiran- 1800-599-0019
5. Snehi India - +91-9582208181
6. Voice that cares- 8448-8448-45
7. Connecting trust- 9922004305, 9922001122
8. NIMHANS Psychosocial Support Helpline- 080 4611 0007
9. Vandrevala Foundation- +919999666555

For further support, reach out to:

Dr. Priyanka Halwasiya Ms. Shreya Singhal

Child and Adolescent Psychologist Child and Adolescent Psychologist
Sir Ganga Ram Hospital Sir Ganga Ram Hospital
9811420761 9810022980

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