When family members find out about a loved one who self injures, most feel at a loss.  They might begin to question their past behavior toward their child/relative and worry that, from now on, every word or action will prompt an incident of self-injury.  Family members usually describe initial feelings of shock, fear, confusion, and frustration.  Many fear that their child/relative will commit suicide.

Family members of self-injurers often agonize about how to approach the topic.  Some relatives want to deny the problem or think the behavior is too crazy to accept or understand.  Others are worried about how this behavior will reflect on them.

Intervention Tips

The first thing to do when you suspect, or find out, that your loved one is self-injuring is to think through how you are going to respond.

If you are only suspicious, then ask your child/relative if they are physically harming themselves.  If you know they are, tell them that you are there to help.  Share your concerns in a nonjudgmental manner.  Tell them that you know they must be in a lot of emotional pain, and you are sorry that they are ‘needing’ to do this in order to feel better.

If they say, “it’s no big deal”, ask them if the reason they are saying that, is because they fear you’ll get mad.  If they answer no and continue to minimize the behavior, then tell them that you would like to get a professional evaluation.  Ask them if they have had thoughts of suicide.  If they say yes, then ask if they have a plan.  If they do, then get immediate professional help by taking them to an emergency room or psychiatric hospital for an evaluation.

If they say no, then ask them if they know why they self-injure and whether or not they are scared.  Tell them you’ll be there to listen to whatever they have to say.  Be prepared to hear things that may be difficult for you to accept.  If you know that you have not always been there for them, consider telling them that you will be there for them now.  If you are sorry, tell them so, even if it wasn’t under your control (e.g., illness, divorce, job demands, etc.).  Tell them that self-injury is not something they have to, or should, deal with by themselves.  Things not to do or say:

1. Display anger
2. Tell them to just stop it
3. Injure yourself – to show them how it makes you feel when they self-injure
4. Think of it as ‘just a phase’, or ‘just for attention’
5. Punish or ground them

In our book Bodily Harm: the Breakthrough Healing Program for Self-Injurers we answer such questions as:

1. What are the warning signs that someone is doing harm to themselves?
2. What should I say or do— avoid saying or doing— in such a circumstance?  Should I confront them?  How?
3. They won’t open up about the problem.  How can I get them to talk to me?
4. When they finally did talk to me, I didn’t know what to say to them.  Help!
5. Should I try to get my loved one to stop the behavior? Are there any strategies that work?
6. What do I do if they refuse to acknowledge a problem or to get help for it?
7. Who should I tell—or not tell— about the problem?  Does the school or place of employment need to know?
8. The rest of the family is beginning to suspect something is wrong.  What should I tell them?
9. What should a parent who self injures tell young children about the problem?
10. My sister doesn’t want her children to be around my daughter who has been self-injuring.  What should I do about this?
11. How do I support the healing process of someone who injures, without falling into the ‘rescue’ trap—or inadvertently prolonging the behavior?  How do I stay healthy while supporting them at the same time?
12. As a parent of a self-injurer, should I blame myself?  How should I deal with my child’s anger and disappointment?
13. How do I cope with the frustrations, fear, and anger I feel about the injurer’s behavior?
14. My loved one is in the process of healing and has just gotten home from the hospital. What can I expect from them?  When are they cured?  Do I have to watch what I say or do?

If you are a boyfriend, girlfriend, a best friend, or just a friend of someone who self-injures it is important that you take care of yourself first.  People who self-injure often put friends (intentionally or not) in helpless situations.  A common request of a self-injurer is to ask a friend not to tell anyone else about their self-injury.  They may hold you ‘hostage’ with the threat, “if you tell….. I’ll cut myself”.  You may think you always have to be available so that they do not self-injure.  Friends tend to want to help the self-injurer in any way that they can, even if the self-injurer does not want the help.  Knowing how much, and how often to intervene can be overwhelming.  Setting boundaries within the relationship or deciding when to let go can also be stressful.

Intervention Tips

1. Tell your friend that you cannot keep their self-injury secret.  Explain to them that it puts you in an uncomfortable position.  Tell them you will confide in people that you think can help (teachers, school counselor, school nurse, clergy, your parents, therapist, family doctor….)
2. Know your limits.  Are you spending more time worrying about your friend self-injuring, and less time about your needs?
3. If your friend self-injures and blames you, tell them that you are not taking responsibility for their self-injury.  This scenario is most common after a ‘break up.’ The self-injurer may tell you, “if you leave me I’ll injure.”  Do not stay in the relationship as a result of manipulative threats.  Tell them that you hope they will take responsibility for their behavior, not self-injure and get the help they need.
4. Let them know that you are willing to help them look for information regarding treatment options.
5. Remember, a healthy relationship is one of honesty, compromise, and communication.

Many people who self-injure have had to seek treatment for their self-inflicted wounds in an emergency room. Many of them have shared their stories with us regarding their emergency room experience. What surprised us more than their stories was the fact that their experiences are so similar. Here are some examples:

1. Most who needed sutures were barely, if at all, anesthetized. The staff saying things like “since you like pain you should be stitched without anything to block the pain.”  Some staff wants to make the patient’s experience so painful in an effort so that they will not injure again. Another staff has been noted saying in disgust that they would rather treat “real patients.”
2. Most patients are told that they were trying to kill themselves (which most patients state that they were not suicidal at that time) and a psychiatric consult is ordered. Many say that they wait for hours in a room by themselves until the consult takes place.  The patient finds this scenario ironic, because if they were trying to kill themselves then why are they left alone for so long?

It is understandable that most people usually recoil from pain, and to come across someone who intentionally harms themselves can be disturbing.  When the medical staff sends negative verbal and non-verbal messages to the patient it only compounds the patient’s shame, and does not provide a positive example of how to appropriately manage discomfort.

People who injure do so as a way to manage affect states.  Their self-esteem is poor and they have little impulse control.  Due to their poor self-esteem, some repeatedly and intentionally subject themselves to emergency room abuse, but most go there reluctantly to receive medical treatment for their wounds.  Many people who self-injure have either learned to treat themselves or just neglect their injuries in order to avoid the emergency room ridicule.

Intervention Tips

If you know or suspect that the wounds were self-inflicted, ask the patient if they are receiving psychological help.  If they say “yes”, encourage them to contact their therapist.  If they do not have psychological support, ask them if it would be okay to refer them to someone who can assist them in locating resources for treatment.

Ask (don’t tell them) if the self-injurious act was a suicidal gesture.  If they deny any suicidal intent, tell the patient that you want to believe them, but you need to know more about the drive behind the behavior.  Ask the patient if they know the difference between a suicide attempt versus a self-injury act.

Most self-injurers are quite clear in this matter and able to verbalize the difference. They are somewhat insulted when they are not believed.  If you are not convinced with the patient’s self-assessment, let them know that you are not comfortable with discharging them until someone can do a more comprehensive psychiatric evaluation.

Many of our clients utilize crisis hotlines.  Unfortunately, they don’t always know how to ask for the support that they need.  For example, they may say, “I want to cut myself”, or “I am going to harm myself”.  Based on what our clients tell us, many crisis workers will automatically interpret these types of statements as suicidal and dispatch police to the caller’s location.  Although some of our clients report that they have attempted to explain that they were not trying to kill themselves, the police were sent anyway.  At times, however, the self-injurer will put the crisis worker in an untenable position, leaving no choice but to call the police.

Intervention Tips*

1. After listening to the self-injurer, ask them if they have a plan to kill themselves.  If they say yes, then clearly, the police need to be called. If they say deny suicidal ideations with a plan, ask them if they would tell you if they did.  If they say “no”, then call the police. Ask them if they always know the difference between wanting to injure and wanting to die.  If they say no, then call the police.  Most self-injurers do know the difference and will say they have thoughts but no imminent plan.  If this is the case, then follow tip #2.
2. In general, self-injurers just want someone who is willing to listen.  They are in acute emotional distress; want to know that they are not alone, that someone cares enough to listen, and to help them think things through during this time of crisis. At times, the self-injurer might say something highly provocative or put the crisis worker in a double bind (a no-win situation).  An example would be “I just want to be left alone so that I can do what I want to do”.  If you tell them you won’t leave them alone and that you’re going to call the police, then you’re vilified for taking control against their wishes; if you do nothing, then you’ll be accused of displaying a total lack of interest in their well-being.  A better response would be to put it back on the caller by saying, “I’m not sure how you want me to respond to that.”  This often helps the client think through what it is they do want from you.  If, however, they remain vague and will not contract for safety, then the police will need to be called.
3. Ask the client why they are now having thoughts of wanting to self-injure.  If they deny knowing why ask them about their day (e.g., phone calls, conflicts, upcoming events, etc.).
4. Often self-injurers are trying to numb themselves from intense feelings such as anger, sadness, a sense of aloneness, etc.).  Ask the caller what they are afraid would happen if they don’t injure (e.g., ‘go crazy’, ‘start crying and never be able to stop’, ‘explode’).  Attempt to challenge any irrational thoughts.
5. If the caller tells you that they have self-injured, ask them if they need medical attention.  If they say they are not sure, ask them what they did, and if the injury sounds serious (e.g., will not stop bleeding, any kind of burns, swallowed anything that is not food, injected any substance, swollen tissue, etc.) strongly encourage them to get medical attention immediately.
6. Avoid suggesting substitute behaviors such as drawing on the skin with a red marker, holding ice, snapping a rubber band on the skin, etc.

*Please note that the information contained in this section is not intended to supersede the policies and protocols set forth by the agency in which you are employed.  This information is to be used as a supplement or to encourage the development of future policy and education of the professionals that intervene with self-injuring clients.