Content warning: Discussion of self-harm and mentions of suicide
Self-harm is a health issue that affects people around the world — yet it remains taboo. As a result, it can be difficult to understand non-suicidal self-injury. And without understanding, it may feel impossible to help a loved one who is struggling.
Mark Schechter, MD, a Mass General Brigham psychiatrist and chair of the Department of Psychiatry at Salem Hospital, answers common questions about how to help someone who’s self-harming.
Self-harm, or non-suicidal self-injury (NSSI), is the act of intentionally hurting oneself. It may feel difficult to understand, but people who engage in NSSI are not trying to end their lives. Often, they are harming themselves to release or manage big, painful emotions.
“We differentiate self-harm from a suicide attempt by intent,” explains Dr. Schechter. “Did the person have some intent to die, or was it some other motivation like the relief of distress?”
When we think about self-harm, we mostly think about deliberate damage to the body. This may include actions such as:
But, as Dr. Schechter explains, “Self-harm can also include less obvious ways of hurting yourself, like drinking, using drugs to dangerous excess, putting yourself in dangerous sexual situations, or depriving yourself of food.”
“Most people self-harm because they have unbearable feelings that feel like there’s no other way to get rid of them,” explains Dr. Schechter, “and self-harm offers some relief. These feelings can be intense: anguish, desperation, a feeling of entrapment, which is a sense of desperation with a perception that there's just no other way out.”
Self-harm might seem like a contradictory idea. After all, it does create pain. But for people who self-harm as a coping technique, the pain offers relief from emotional suffering. Some people note that people who self-harm show common signs of addiction. That feeling of relief can be potent and rewarding, which makes it hard to stop self-harming.
There is a common misconception that people self-harm to get attention. As Dr. Schechter explains, this usually isn’t the case. In fact, people often conceal self-harm out of shame and guilt, which is very much the opposite of ‘looking for attention.’
“Mostly people self-harm because of this feeling of unbearable distress and they can't figure out any other way to get relief,” Dr. Schechter explains. “There are times when people self-harm as a way of communicating distress that they can't put into words like, ‘I need help.’ But we also can’t assume that that's the primary motivation."
Sometimes self-harm can be obvious. For example, you may see fresh cuts or burns on a loved one’s arms or legs, or blood stains on their clothing. But often, it isn’t clear, and people may self-harm out of guilt or shame.
Dr. Schechter explains. “Some warning signs that someone might be self-harming might be frequent cuts and unexplained bruises or scars. Sometimes, people wear long-sleeved shirts or pants all the time, no matter what the weather is. Or scarves or turtlenecks to conceal scars on the arms, legs, or neck.”
You may notice a sudden change in behavior or mood. A person may experience rapid, exaggerated mood swings; they may also appear depressed and hopeless. They might even express feelings of worthlessness.
“Self-harm is surprisingly common,” explains Dr. Schechter. “It’s generally thought that females harm themselves more than men, and this may be so. But it may be closer to 50-50 than we think. That’s because a lot of the behavior that males tend to do, like provoking a fight and getting hurt, punching a wall, drinking, or using drugs to excess, are often not categorized as self-harm.”
Self-harm is most prevalent among teenagers. But it does still happen in adults, particularly if they have a history of early trauma or certain psychiatric illnesses such as major depressive disorder (depression) and bipolar disorder. NSSI is also more common in people who identify as non-heterosexual or transgender. The experience of being bullied or victimized by peers is also a risk factor for self-harm.
“The short answer is no,” explains Dr. Schechter. "The vast majority of people who self-harm do not go on to die by suicide. But the relationship between self-harm and suicide is complicated because self-harm, even non-lethal self-harm, is a risk factor for suicide."
This is one of the reasons it's so important to get help for self-harm right away before it becomes harder to stop.
If you’re ready to stop self-harming, it’s important to reach out for help first and foremost. Family, friends, colleagues, loved ones, and whoever you can trust can offer support.
Get professional help from a licensed therapist and consider getting evaluated for medication. If you don’t know where to start, talk to your primary care provider (PCP). They can connect you to a therapist who can help you recognize your self-harm triggers and prepare healthier ways to soothe yourself.
You can replace self-harm with other behaviors such as exercise, music, art, taking a walk, or vigorous exercise. Some people find a hot shower or a bath helpful. Others enjoy punching a punching bag, or some other vigorous, even slightly painful activity like a tough workout.
It's critical to start with compassion — not criticism. Try to remember that self-harm comes from someone feeling such bad feelings that they can't bear it and can't figure out any other way to get rid of them. People who self-harm often feel guilty, ashamed, and alone. Just making them feel heard and seen can be an enormous relief.
Ask questions and listen without judgment. Be careful about giving too much advice or talking too much about your own experiences. Be willing to ask about suicidal thoughts. This can feel uncomfortable, but it's important. If someone's suicidal, they need to go to an emergency department for care right now.
Having an open dialogue about self-harm and the feelings that fuel it is one of the most important things you can do to ensure that people feel comfortable reaching out to you and seeking help. And if you're struggling yourself, reach out to someone you trust. You are not alone with this. Asking for help is the first step toward recovery.