Beyond skin deep

After the first girl, I always had a watchful eye when working with kids. The long sleeves on a warm day. The wrist guard fashion accessory that is always on. The refusal to put on a bathing suit. Every time one of these signs surfaced, the same thought ran through my mind: Could she be a cutter?

Cutting, one of the many types of deliberate self-harm, is a present reality in most of our youth ministries. Studies show that between 14-39% of adolescents have had at least one incident of deliberate self-injury. [Statistics for self-injury widely vary because of the hidden nature of the condition and many adolescents’ fear of coming forward. Best estimates put rates of self-injury in adolescents between 14-39%. Matthew K. Nock and Mitchell J. Prinstein, “Contextual Features and Behavioral Functions of Self-Mutilation Among Adolescents,” Journal of Abnormal Psychology, (vol. 114, no. 1, 2005) 140-146.] Because of the hidden and shameful nature of self-injury and the real physical damage that occurs, it can be difficult to understand and scary to help. Yet the prevalence of self-harm means we need to become more equipped to care for these kids.

Defining self-injury

Self-injury is often misunderstood because it seems counterintuitive and mysterious, so it is important to understand what it is and what it is not. Self-injury can be defined as the intentional harm of one’s body tissue through socially unacceptable behavior, normally in reaction to psychological crisis, and without suicidal intent. [K. Ryan, M.A. Heath, L. Fischer, and E.L. Young, “Superficial Self-Harm: Perceptions of Young Women Who Hurt Themselves,” Journal of Mental Health Counseling (vol 30, no 3, July 2008) 238-239.] To break that definition down further:

1. It is not socially acceptable behavior. Self-injury excludes socially acceptable self-harm such as piercing, tattoos, violent sports, and high-risk behaviors. [Though expert Dale Ryan points to these other behaviors as evidence of a culture that glorifies self-violence.]
2. It is not due to mental impairments. Self-injury should also not be confused with the self-harming behaviors of those with mental impairments such as schizophrenia.
3. It is not suicide. Although self-injurers may be suicidal, self-injury is not a failed suicide attempt. Instead, many youth describe self-harm as an “anti-suicide”, using self-injury as a coping mechanism to actively avoid killing themselves. [Jacqueline Mangnall and Eleanor Yurkovich, “A Literature Review of Deliberate Self-Harm,” Perspectives in Psychiatric Care (vol 44, no 3, July 2008) 177.] Kids who cut are trying to overcome their physiological distress with self-injury, choosing to self-injure rather than self-destruct.

Although cutting is the most common form of deliberate self-injury, teens may also harm themselves through severe scratching, burning, banging, hitting, hair pulling, inserting objects under their skin, or by using a combination of these behaviors. [70% of adolescents that self-injure cut themselves, and most have used multiple methods. E. David Klonsky and Jennifer J. Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” Journal of Clinical Psychology: In Session (vol 63, Nov 2007) 1046.] Self-injury can occur anywhere on the body, but common areas include the arms, hands, wrists, thighs, and stomach. [Klonsky and Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” 1046.]

Who self-injures?

It could be easy to assume that one sub-group in your youth ministry is more at risk for self-harm than others, but self-harm is not limited to one gender, race, socio-economic group, or age. It is just as likely for the “emo” girl to be a cutter as the “jock” guy, and we have to be careful not to make assumptions about who might or might not be cutting.

Many assume that self-harm is mainly an issue for girls, but studies show that 20-50% of self-injurers are male. Males are more likely to burn or hit themselves in self-harm than females, which may be less likely to be noticed than the telltale cuts more often exhibited by girls. [“Although the prevalence of DSH is unknown, it appears to be fairly common, and most episodes are unreported,. It seems to affect males and females equally, although females are more likely to seek help or to be discovered.” Armoando R. Favazza, Bodies Under Siege: Self-mutilation in Culture and Psychiatry (Baltimore, MD: Johns Hopkins University Press, 1987), 206. Some studies have found that rates are about equal between men and women for self-injury, with females more likely to cut themselves and males more likely to burn or hit themselves. Klonsky and Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” 1047. Other studies have found that up to 80% of high school self-injurers are female. Karen Conterio and Armando R. Favazza, “The Plight of Chronic Self-Mutilators,” Community Mental Health Journal (vol 24(1), Spring 1988) 22-30.] Self-harm is also present among all ethnic and racial groups, but some studies suggest rates are higher among Caucasians. [Klonsky and Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” 1047.]

We tend to think that if students are functioning well in the obvious areas (school, sports, general health), they are doing fine. However, kids can be fully functioning, and may even appear to be thriving, while keeping a deep secret of self-injury. We cannot assume that only the students who appear to be struggling externally are at risk for self-injury.

Warning signs of self-injury include unexplained cuts, scratches, or bruises, long sleeves or pants in warm weather, refusal to wear a bathing suit, or a collection of possible self-harming tools and bandages. Mood swings, changes in relationships or school performance, difficulties in handling emotions, and withdrawal can also be warning signs of self-injury.

If you are worried that a kid may be self-injuring, one of the best steps you can take is to intentionally create a safe place where they can share and let them know you are available to them.

The cycle of self-Injury

Self-injury can be very difficult to understand. For many, it seems nonsensical for an adolescent to cut himself or herself in an effort to get better. Yet to a kid in the midst of the cycle, self-harm may be the most logical coping mechanism for the pain or distress they feel.

Dr. Dale Ryan, Professor of Recovery Ministry at Fuller Theological Seminary, presents the following cycle of self-injury. [Dale Ryan. Self Harm: Helping Adolescents Who Hurt Themselves. Lecture, L.A. Youth Ministry Network, Pasadena, CA. March 2009.] This cycle reflects the psychological dynamics of many kids who self-injure and can help youth workers and parents understand the process of self-harm.

Emotional Suffering. Adolescents who self-injure may experience emotional suffering that emerges from various sources. Traumatic incidents in their past, difficult home or school lives, issues with friends or boyfriends/girlfriends, abuse, depression, low self-esteem and self-loathing, stress, perfectionism, or addictions can all lead to emotional suffering.

Emotional Overload. Emotional overload occurs when the emotional suffering becomes too great for the adolescent to cope. There is a buildup of tension, normally from feelings of depression or anxiety. [Mangnall and Yurkovich, “A Literature Review of Deliberate Self-Harm,” 179.] Teenagers may feel angry, anxious, frustrated, depressed, hopeless, or hostile. This emotional overload can lead to dissociative episodes, in which students feel detached from reality. [Mangnall and Yurkovich, “A Literature Review of Deliberate Self-Harm,” 180.] They lose their ability to identify, understand, or articulate their emotions, making it difficult to cope with them. [Klonsky and Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” 1047.] Turning inward, the overload can lead to increased self-hostility and a sense of losing control. [Mangnall and Yurkovich, “A Literature Review of Deliberate Self-Harm,” 180.] Some kids alternate between feeling numb and feeling overloaded.

Panic. All of this can lead to panic. The kid may feel rising anxiety, not knowing how to stop the hostility or bring himself or herself back to feeling reality.

Self-Harm. To stop the rising panic and anxiety, the next step may be self-harm. As one self-injurer describes: “I injure myself to try to calm down, to try and escape the painful memories of my abuse, to try and take control of my emotions, to try to feel safe, to stop the nightmares and day-mares, to try and feel.” [Mangnall and Yurkovich, “A Literature Review of Deliberate Self-Harm,” 181.] For some, cutting the skin is a symbolic opening through which the tension and panic they feel can escape. [Favazza, Bodies Under Siege, 204.] For others, self-injury gives them a sense of control over the pain that they feel, turning overwhelming emotions and psychological pain into physical pain that can be located and controlled. [Ryan, Heath, Fischer, and Young, “Superficial Self-Harm,” 241. Klonsky and Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” 1049.] Others use self-injury to break the dissociative episodes and bring them back to reality. [”...feeling generation is another term that can be used to refer to the antidissociation function of self-injury. Reasons sometimes identified for self-injury include, ‘to feel something even if it is pain,’ ‘to feel real again,’ or ‘to stop feeling numb.’” Klonsky and Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” 1050.]

Temporary Relief. Researchers have documented a sense of biological and/or psychological relief that comes immediately after incidents of self-harm and can last up to 24 hours. [Studies have measured the cortisol levels in self-injurers, a hormone associated with stress levels, and found that cortisol levels generally rose in the period before self-harm and instantaneously returned to baseline levels after self-harm. Mangnall and Yurkovich, “A Literature Review of Deliberate Self-Harm,” 181.] Adolescents experience a very real relief when they self-injure, which makes self-harm seem like an effective coping mechanism. But the relief is only temporary and leads back into the cycle of self-harm.

Shame/Grief. Self-injurers feel guilty about incidents of self-harm and their inability to stop themselves. These feelings of shame and grief contribute to the emotional suffering of the adolescent, thus continuing the cycle.

How we can respond

Finding out about kids’ self harm can be both shocking and frightening, and it’s certainly overwhelming to think about how to respond appropriately as a youth worker or parent. If someone tells you about self-injury, here are some practical tools to help you respond:

• Do not judge or overreact. Many adolescents keep self-harm a secret because they are afraid of being judged. If you find out that someone in your youth ministry is self-injuring, stay calm and manage your own anxiety. Do not react with panic, shock, anger, or crying. Don’t accuse the adolescent of cutting to get attention or to manipulate others. Overreacting, threatening, scolding, self-blaming, or making negative comments will only increase their feelings of guilt, isolation, and panic, likely causing them to return to the cycle of self-injury.
• Be understanding and empathetic. Self-injurers need to know that they are not alone and that someone understands and validates them. Let them know you care about them, respect them, and still think positively about them. Know that self-injury is a symptom of deeper problems in the kid’s life and try to understand the issues that are leading to self-harm.
• Acknowledge the severity of their distress. Self-injurers report that the most helpful thing that you can do is acknowledge the depth of their pain and its impact on them. [In a survey of self-injurers, 86% said that the thing they perceive as most helpful is someone acknowledging the severity of their distress. Ryan, Heath, Fischer, and Young, “Superficial Self-Harm,” 244.] Take them seriously and let them know you see their pain.
• Encourage them to verbalize their feelings. Self-injurers want someone to listen to them and help them talk about their emotions. Self-injury is itself a form of communication, and letting the adolescent talk without fear can help mitigate self-injury. Learning to articulate emotions can also help break the dissociative episodes that lead to self-harm. Be an active listener, giving the adolescent space to talk about why they self-injure and how it makes them feel. Ask questions, but be careful never to sound accusatory or force them to share.
• Make yourself available. In a survey of self-injurers, 81% said that it was helpful to know that someone was simply available to assist them if they needed it. [Ryan, Heath, Fischer, and Young, “Superficial Self-Harm,” 244.] Ask how you can be helpful. Work with the student to set up a network of caring and understanding adults that can be available to them when they feel like they may self-injure or when they need help.
• Never try to control their behavior. Reports have found that taking away self-harm tools, forcing kids to reveal new self-injuries, or threatening them with punishment all make self-injury worse. [Ryan, Heath, Fischer, and Young, “Superficial Self-Harm,” 244.] Forcing a self-injurer to go to professional help against their will is also harmful and will increase their stress and likeliness to self-harm. [Ryan, Heath, Fischer, and Young, “Superficial Self-Harm,” 246.]
• Work on harm minimization and alternative coping strategies. Studies show that it is better to work towards lowering the amount of harm rather than trying to stop it altogether. [Mangnall and Yurkovich, “A Literature Review of Deliberate Self-Harm,” 182.] Talk together about alternatives to self-harm that they might be able to use, such as holding an ice-cube in their hand until it burns or calling a trusted adult. Help them consider minimizing harm by not cutting as deeply or burning as badly.
• Be aware of other issues. The negative emotions that lead to self-harm often lead to additional unhealthy coping mechanisms like eating disorders and substance abuse. [“There is also reason to believe that self-injury often co-occurs with eating disorders such as bulimia and anorexia. Disordered eating behaviors such as binging and purging may be prompted by negative emotions comparable to those that tend to precede self-injury…. Individuals suffering from substance disorders are more likely to self-injure. Self-injury and substance abuse both involve causing harm to the body physiologically, and therefore similar psychological processes may underlie the behaviors.” Klonsky and Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” 1048. ”Behaviors associated with SSH often co-occur with such mental health disorders as generalized anxiety disorder, posttraumatic stress disorder (PTSD), BPD [Borderline Personality Disorder], and antisocial personality disorder…. In general, those who engage in SSH often struggle with depression and anxiety.” Ryan, Heath, Fischer, and Young, “Superficial Self-Harm,” 240-241.] Other harmful factors may also be leading to the self-harm, such as depression, suicidal tendencies, anxiety disorders, posttraumatic stress, or a history of abuse. We need to be aware of other possible issues and deal with self-harm as part of a larger network of problems. Ask them about other ways they cope and the different sources of pain and anxiety in their lives, being watchful for other issues that may be harming them.
• Work with family and friends. In a study of self-harming adolescents, friends were perceived as being the most helpful and parents were perceived as being the least helpful in dealing with self-injury. [In this study, coaches and religious leaders were perceived as being neutral in their helpfulness. Ryan, Heath, Fischer, and Young, “Superficial Self-Harm,” 245.] Since the self-injurer may have turned to friends first, we need to make sure those friends aren’t overwhelmed and are encouraging their friend to get adult help. With the self-injurer’s permission, help educate the friends about self-injury and how they can be supportive. Finding out their son or daughter is self-injuring can be devastating to a parent, causing them to overreact out of fear, shock, anger, or self-blaming. Help them understand self-injury and the ways they can best help their child.
• Encourage professional help or advice. Unless you are a trained counselor, encourage the adolescent to find professional help. If they do, remain in an active role in the adolescent’s life and be supportive of their recovery.

Preventing Self-Injury

Self-injurers normally self-harm for the first time around age 13 or 14, meaning many of us are involved in the lives of youth during an influential timeframe. [Klonsky and Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” 1046. ] By being a caring and supportive community to kids, our youth ministries and churches can help prevent self-injury from starting in the first place. Here are a few ways we can work towards prevention:

• Create a safe space for sharing and honesty. One of the greatest things we can do in youth ministry create a safe place where adolescents can share about the pain, stress, and tough situations in their lives. Focus on building relationships between kids and adults and creating an open environment where students know they can be honest and accepted.
• Model healthy ways to cope with negative emotions and overwhelming situations. Help kids learn how to handle their emotions and stress in positive ways. When conflict, anger, or frustration occurs at youth group, work together to find healthy coping mechanisms. Be open about the ways that you cope in your own life.
• Teach theology that values the body. Self-injurers sometimes believe that their bodies are sinful, using self-injury as a form of punishment or penance for sin. Let students know that they are made in the image of God and that their bodies are part of God’s good creation for God’s worship and service. Be careful of theologies of sin that could lead students to believing that their bodies are disgusting.
• Encourage a healthy body image. Make youth group a place where kids can feel good in their skin. Serve healthy food and have options for all levels to get involved in physical activity. Talk with youth who are struggling with body image or putting others down.
• Educate co-workers, volunteers, and parents. Work with other adults in the church to create a community where kids are embraced and supported through tough stuff. Equip adults with ways to respond to self-injury before they are confronted with it.
• Communicate hope. Finally, when ministering to an adolescent who self-injures, be hopeful. Most adolescent self-injurers who receive help and support do not become lifelong self-harmers. [Klonsky and Muehlenkamp, “Self-Injury: A Research Review for Practitioners,” 1046.] There is hope and healing for these kids, especially within a supportive church community where they are allowed to share their hurts.

Photo by Tim Foster

Amazon Affiliate links are included in this blog post. FYI earns from qualifying orders placed through links in this post.