A study published last July in the American Journal of Public Health revealed a troubling set of statistics about the prevalence of self-harming behaviors among adolescents in the United States. In a sample set of over 60,000 teens, researchers found that:
- More than 17% of adolescents reported engaging in self-harming behavior
- Roughly 11% of adolescent males reported engaging in self-harming behavior
- Around 24% of adolescent females reported engaging in self-harming behavior
If we extrapolate from this set – which is large enough – and generalize to population-size numbers for the U.S., these percentages take on new meaning. On average, between 2001 and 2015, over seven million adolescents engaged in some type of self-harming behavior each year.
That’s close to two million boys and over five million girls.
That’s a lot of kids – and that’s why we should pay attention to these figures. The numbers for girls, which doubled between 2009 and 2015, deserve special attention. Experts are not certain what’s responsible for the increase in self-harming behaviors in adolescent females. Many experts theorize the rise and prevalence of social media explains the increase. This makes sense to most people who understand the role social media plays in many teen’s lives. But while some studies connect social media use with anxiety and depression – which themselves can, in some cases, lead to self-harming behavior – no studies to date offer conclusive data linking social media and self-harm.
That’s why a new study, called “Efficacy of Dialectical Behavior Therapy Versus Treatment as Usual for Acute-Care Inpatient Adolescents,” published this spring in the Journal of the Academy of Child and Adolescent Psychiatry is notable. It doesn’t explain why more teens, especially girls, are engaging in self-harming behavior, but it does offer evidence on the effectiveness of one mode of therapy used to treat adolescents who self-harm: Dialectical Behavior Therapy (DBT).
What is Self-Harm?
Before we dive into the study, we should get on the same page about what self-harm means. The National Alliance on Mental Illness (NAMI) offers a short definition:
Self-harm means hurting yourself on purpose.
While that is accurate, at the most basic level, the American Psychological Association (APA) offers a comprehensive definition, which is more helpful for clinicians and their patients:
“The condition – clinically known as non-suicidal self-injury or NSSI — is characterized by deliberate self-inflicted harm that isn’t intended to be suicidal. People who self-harm may carve or cut their skin, burn themselves, bang or punch objects or themselves, embed objects under their skin, or engage in myriad other behaviors that are intended to cause themselves pain but not end their lives.”
One thing about NSSI that most people don’t understand is that in most cases, it’s not done with the intent to die.
Incidents like self-cutting or burning, for the most part, are not failed suicide attempts. They are, however, clear and unmistakable signs that the person engaging in them is in severe emotional pain. The physical pain they create by harming themselves – according to those who do it – is an attempt to make the emotional pain disappear, temporarily. The physical pain masks the emotional pain. And in the aftermath of the incident, the emotional pain – and/or the uncomfortable, distressing patterns of thought present before the incident – fades or disappears entirely for a short period of time. This means that self-harm is a coping mechanism. Teens develop it in order to process overwhelming emotions they don’t understand, may not be able to identify clearly, and have no idea how to handle in a productive manner.
Self-Harm and Suicide: Is There a Connection?
Yes.
However, it’s important to understand that NSSI and suicidal ideation (SI) and suicide attempts (SA) are not the same thing. Whereas NSSI is a coping mechanism designed to preserve and continue life – the harm is an attempt to mitigate emotional pain in order to keep moving forward – suicidal ideation and suicide attempts are thoughts and efforts that indicate a desire to end life altogether.
With that said, parents, teachers, and mental health professionals should take self-harm seriously. They should take it as seriously as they take suicidal ideation or attempts.
Why?
Studies show that adolescents who engage in self-harming behaviors are at increased risk of suicidal thoughts and behaviors later in life. The level of risk increases for adolescents who engage in severe forms of NSSI. Risk also increases for those diagnosed with specific mental health disorders. Researchers at Cornell University indicate that, compared to those who engage in NNSI but are never suicidal, people who engage in both NSSI and suicidal thoughts and behaviors are more likely to report:
- Diagnosis of a mood or behavioral disorder, such as major depressive disorder (MDD) or post-traumatic stress disorder (PTSD)
- Twenty or more incidents of NSSI
- Past sexual or emotional trauma
- Alcohol or substance use
- Recent psychological distress
- Family conflict
- Impulsivity and risk-taking behaviors
It’s also important to understand NSSI, its risk factors, and the recent increase in prevalence in the context of another metric: the increase in suicide rates for adolescents and young adults. Data from the National Institute of Mental Health (NIMH) show that in 2017, suicide became the second leading cause of death for people age 10-34 (yes, that includes three groups typically discussed separately: 10-14, 15-24, and 25-34), and the fourth leading cause of death for people age 35-54 (includes those 35-44 and 45-54).
Treatment for Self-Harming Behavior
The prevalence statistics tell us there are millions of young people who engage in NSSI and self-harming behaviors. Years of evidence teaches us that treatment for mental health disorders can help people manage their symptoms and live a life they choose, rather than one dominated by their symptoms. Numerous psychotherapeutic approaches help those living with depression, anxiety, bipolar disorder, borderline personality disorder, and alcohol/substance use disorders. Talk therapy, group therapy, behavioral therapy, and medication can all be life-changing for people who live with mental health disorders.
But what approach works best for adolescents who self-harm?
The study we mentioned above, “Efficacy of Dialectical Behavior Therapy Versus Treatment as Usual for Acute-Care Inpatient Adolescents,” presents evidence that one specific approach – dialectical behavior therapy (DBT) – is an effective approach to treatment for teens who self-harm.
Researchers examined the records of 425 adolescents who met the following criteria:
- Hospitalized for suicidal ideation (SI), suicide attempt (SI) or non-suicidal self-injury
- Received inpatient DBT therapy
They compared their records to adolescents who met these criteria:
- Hospitalized for suicidal ideation (SI), suicide attempt (SI) or non-suicidal self-injury
- Received inpatient treatment as usual (TAU)
Compared to patients who received TAU, patients who received DBT had:
- Fewer days in hospital
- Fewer hours in restraints
- Decreased suicide attempts
- Decreased self-injury incidents
- Fewer hours of constant observation (CO) for self-injury
Also, researchers determined that the use of DBT therapy resulted in a reduction of cost related to staff time involved in CO. Staff time for CO for patients who received DBT cost $251,609 less than staff time for CO for patients who received TAU.
This is compelling evidence for the implementation of DBT as treatment for adolescents who engage in self-harming behavior. It shows reductions in key metrics related to NSSI, SI, and SA. Additionally, it’s less expensive, overall, than treatment as usual. While outcomes concern us more than cost, we recognize that cost is a significant barrier to treatment for many families. We advocate of any evidence-based practice that can remove barriers to treatment for teens who need it.
Help for Teens Who Self-Harm
One way to understand the value of the data presented in this new study about DBT, as well as the overall prevalence statistics from the AAP study mentioned at the beginning of this article, is to recognize that raising awareness about on the part of the parents, school officials, and mental health professionals is crucial to the ongoing health and wellness of our youth.
In some cases, the issues that lead to self-harm can be severe. Bipolar disorder, depression, anxiety, PTSD, substance abuse, or defiance disorders can all contribute to or exacerbate self-harming behavior. Self-harm and those underlying causes need to be addressed by qualified professionals. Evidence shows that with the proper treatment, teens who self-harm can learn to manage their emotions without harming themselves. When teens with an emotional disorder receive the right treatment, their lives can improve dramatically. In this case, data shows the right treatment for teens who engage in NSSI is DBT.
It takes work and the help of a professional, but it’s a fact: treatment works.
Self-Harm: Resources for Parents and Teens
Here’s a list of resources anyone – parent, teen, friend, other relative or concerned party – can use right now to start the healing process:
- Parents can find a qualified professional in your area with this psychiatrist finder provided by the American Academy of Child and Adolescent Psychiatry.
- Teens who need help can call or text the following numbers:
- The National Suicide Prevention Lifeline (24/7/365): 1-800-273-8255
- The Trevor Project Phone (24/7/365): 1-866-488-7386
- Trevor Project Text (7 days/wk, 6am-am ET, 3am-10pm PT): Text START to 678678
- The Trevor Project Chat: CLICK HERE
- The Crisis Text Line (24/7/365): Text CONNECT to 741741
- The Youth Yellow Pages TEEN LINE (6pm-10pm PT) 310-855-4673
- The Youth Yellow Pages TEXT: Text TEEN to 839863