Understanding the Intricacies of Self-Harm in Teen Girls

For people who have never engaged in self-harm, the behavior is difficult to understand. When a parent learns their teenage child engages in self-harm, their first response is most often shock. Quickly followed by fear and worry. Anger may be part of the mix, too. A parent may be angry at their child. They may be angry at themselves. Or they may be angry at their spouse or someone else. We understand that. We want to tell parents of teens that engage in self-harm that it’s okay to have those emotions. The best way to handle them is to learn as much as possible about what self-harm is and why teens do it.

We also want parent to know these two things:

Looking for a place to assign blame or a direction to point their anger doesn’t help.

Looking for a way to support their child does help.

When parents learn the why, their emotions most often turn from fear and anger to empathy and understanding. Those emotions may be mixed with confusion and self-blame. That’s okay, too: parents can work through those emotions by seeking emotional support for themselves.

This article is about teenage girls who self-harm, but we want to start by verifying what we’ve said already about the parental experience before we immerse ourselves in the primary discussion about teen girls. An article published in March 2022 called “Adolescent Self-Harm: Parents’ Experiences of Supporting Their Child and Help-Seeking” polled a group of parents about what happened for them when they learned their teen engaged in self-harm. Researchers collected responses and identified two common themes:

1. An emotional journey into the unknown
2. The promise of psychological help

In addition, parents said what they most wanted from mental health professionals were:

• Appropriate referrals, i.e. advice on where to get psychological help for their teen
• A collaborative approach to treatment
• Practical support
• Resources to connect with other parents of teens who self-harm, including parent support groups and personal psychological support

We categorize this article under the umbrella of practical support. We’ll introduce and discuss a study on teen girls who self-harm that focuses on the reasons teenage girls self-harm, as described by teenage girls themselves. As mental health professionals, we know we’re in a better position to help girls who self-harm when we everything we can about what they think and feel when they harm themselves. This article will help parents learn more about the emotions and motivations behind self-harm, which, in turn, will enable parents to better support those girls when they’re most vulnerable.

First, though, we’ll define self-harm and offer the most recent statistics on the prevalence of self-harm in the adolescent population.

What is Self-Harm?

The most widely accepted clinical term for self-harm is non-suicidal self-injury, or NSSI. The American Psychological Association (APA) offers this definition of self-harm:

“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.”

While teens who engage in self-harm may engage in suicidal ideation or go on to attempt suicide at a later date, it’s important for parents to understand that in most cases, teens engage in self-harm not because they want to die, but in order to mitigate, express, or communicate extreme, internal emotional pain.

That’s the first thing crucial thing for parents to understand: when teens harm themselves, they don’t do it because they want to die. Next, it’s important to understand how teens self-harm. Here are the most common forms of self-injury among teens:

• Cutting
• Skin carving
• Burning
• Scratching
• Scraping
• Punching or hitting
• Bone breaking
• Biting
• Pinching
• Preventing/delaying the healing process for cuts or wounds

That’s what self-harm is and the forms it most often takes. Now let’s look at the prevalence rates of self-harm among teens in the U.S. A large-scale study conducted in 2018 that included data on over sixty-thousand teens showed the following:

• 17% of teens said they’d engaged in NSSI
• 11% of male teens said they’d engaged in NSSI
• 24% of female teens said they’d engaged in NSSI

That’s NSSI in the general population of teens. Among teens enrolled in inpatient treatment programs for psychiatric disorders, the numbers are higher. Over 50 percent of these teens report engaging in NSSI. When we look at prevalence from another angle, we learn that 87 percent of teens who engage in NSSI also had a diagnosis for a psychiatric disorder.

But let’s not one point slip by. Prevalence of NSSI among teenage girls is twice as high as NSSI in teenage boys. That’s why the study we discuss below focuses on girls, and what they say about the emotion and motivation behind self-harming behavior.

Why Do Teens Girls Self-Harm?

Published April 2021, the study “The Punished Self, the Unknown Self, and the Harmed Self – Toward a More Nuanced Understanding of Self-Harm Among Adolescent Girls” took a unique approach toward understanding the phenomenon of self-harm in teenage girls. Whereas most research focuses on identifying common risk factors, estimating prevalence rates, and analyzing the relationship between NSSI and various mental health disorders, this study focuses on in-depth interviews with teenage girls in residential treatment for self-harming behavior.

Here’s how the researchers present their primary research question.  In their own words:

Firstly, how do adolescents in a clinical sample describe experiences of their self-harm?

Secondly, are there essential features of how adolescents make meaning of their self-harm?

The first question addresses what the girls think and feel before, during, and immediately after engaging in self-harm. The second question addresses how the girls understand that behavior in the larger context of their day-to-day lives.

Previous research shows that teens – including boys – self harm for two primary reasons. They self-harm for intrapersonal reasons, which means reasons that originate and operate within themselves, and interpersonal reasons, which means reasons related to other people.

Intrapersonal reasons include:

Emotional Regulation

• Teens harm themselves to escape or reduce the effects of negative emotions
• Teens harm themselves to induce positive thoughts or emotions

Interpersonal reasons include:

Communicate Distress

• Teens harm themselves because they don’t know how to tell others they’re in emotional pain
• Teens harm themselves to influence others to notice them
• In some cases, teens harm themselves to punish others and communicate the fact they feel wronged or mistreated

The study we discuss in this article uses these findings as a jumping-off point to further understand the lived experience of girls who self-harm. Again, this study took an interesting approach. They recruited 19 girls currently participating in an inpatient treatment program for NSSI.

Here’s the interesting part: they chose girls who would be informative exemplars rather than choosing a large number of girls. That means the girls were willing to talk, understood their diagnoses and condition, and represented – fairly – trends in girls who engage in NSSI the researchers had previously identified or experienced.

The girls in the study:

• Were between 13-18 years old, average age 16
• Engaged in self-harm 1-3 times per week in the 12-monht period before the study
• Engaged primarily in cutting, scratching, hitting, and/or burning themselves
• All reported suicidal ideation
• Began self-harming at an average age of 13
• Met diagnostic criteria for:
  • Depressive disorders
  • Anxiety disorders
  • Eating disorders
  • Personality disorders

Each adolescent in the study participated in two 60–90-minute interviews. The interviews themselves were conducted by a clinician who established a positive rapport with the participants. Here’s how the interviewer – and lead study author – described the interviews:

“The interviews were open and lightly structured to explore the participants’ subjective experience of their lifeworld, and to capture personal nuances and rich descriptions of concrete experiences of self-harm as part of their practices with family and friends, at home or school or other important places for them.”

Now let’s take a look at the results.

Teen Girls and Self-Harm: In Their Words

The research team identified what they call three superordinate themes. In this context, superordinate means categories that contain several relevant and related subcategories, where identifying categories as superordinate helps group related concepts together to facilitate both understanding and subsequent discussion of the topic at hand.

Here are the three superordinate themes the researchers identified, with descriptions and excerpts of what the girls themselves said about self-harm.

Superordinate Theme #1: The Punished Self. “I Deserve It”

• This theme describes girls who harm themselves because they think they deserve to be punished because they have what they think are unacceptable feelings, thoughts, and needs.
  • One girl in the study said she harms herself because “I feel guilty for the emotions I have toward my family.”
• Girls who harm themselves because they think they deserve it say they harm themselves as an alternative to being angry, assertive, or defensive.
  • One girl in the study said it this way: “It’s like…to harm myself and not eat are ways I can express having a hard time.
  • Another girl said she harms herself because she’s not comfortable being a squeaky wheel: “It’s always those who scream out loudest who get the most support. I think the silent persons also should be taken seriously.”
  • Yet another girl expressed it this way: “People should be interested in what’s BEHIND self-harm. Maybe I use self-harm…to get someone curious and worried.”

Girls in this category want their families and/or friends to know they’re in pain and experiencing confusing, conflicting, and unresolvable emotions, but have no idea how to manage or communicate those emotions, aside from engaging in self-harm.

Superordinate Theme #2: The Unknown Self. “I Don’t Want to Feel Anything.”

• This theme describes girls who are in “a struggle against feelings in general.” They have emotions and thoughts that are overwhelming and can’t control. Their response is that they don’t want those feelings to exist at all.
• Girls in this category report that self-harm becomes a way to gain control of stressful thoughts, emotions, extreme anxiety, and other feelings they can’t identify.
  • Here’s how one of the participants in this category described her experience of self-harm: “Self-harm collects those feelings. Sometimes, when many painful things happen, and you can’t understand…you just feel so much at once, it’s like a storm – it’s much easier to collect it all in ONE physical pain.”
• Girls in this category describe their emotions and thoughts as alien, hard to understand, harder yet to tolerate, and harder still to integrate as a part of a personality they’re comfortable with.
  • This set of emotions is best summarized by the phase “something is wrong with me.”

Girls in this category engage in self-harm to manage emotions, thoughts, and feelings that threaten to overwhelm, debilitate, or paralyze them. In extreme states of anxiety and emotion, they engage in self-harm to both blunt these emotions and communicate to their family and friends that they’re “in a vulnerable state but don’t want to appear vulnerable.”

Superordinate Theme #3: The Harmed Self. “I’m Broken and No One Cares.”

• This theme describes teen girls whose experience of self-harm is characterized by confusion, fear, and living, day-to-day, in a state of being “at risk but left alone.”
  • Girls in this category describe self-harm as a distraction that banishes the difficult feelings and invites better feelings to take their place.
  • Here’s how one study participant described self-harm: “It’s like a drug, in a way – people take it to escape. It gives you a “drug-feeling,” a little happiness. It’s an addiction.”
  • The pain and the result of the self-harm focus their mind on something other than their emotions. Here’s how another study participant put it: “When you cut yourself, you don’t think of anything else. You’re only focused on cutting and the blood.”
• Girls in this category report being harmed or abused at some point in the past, and believe that no one cares.
  • One study participant described “traumatic situations of violence, assault, and abuse during her childhood.” To handle the emotions she felt as a result of these traumatic experiences, she acted out. Here’s how she described her behavior: “I went to school, and then I came back home at 1 a.m. I stole – not because I needed anything, but because it was fun. I went to bars and smoked weed. I had sex with strangers. I was a real […]. I did EVERYTHING at that time. Drugs, you name it.”
  • The girl who offered that quote said she had a hard time believing anyone in her family really cared about her. Here’s why:

“My whole body was covered with scars. Strangely, even people in my own family didn’t notice.”

• • The essence of experiencing self during self-harm is summarized as being offended or abused and involved in risk situations – no one care
• Girls in this category say they engage in self-harm to transform inner pain, psychic pain to real – or physically real – external pain or injury. They agree with the statement “Self-harm is a way I show I’m hurt.”
  • Here’s how one girl described her experience: “I’ve cut myself SO much, in a way, and it changes from screaming to whispering, in a way, you don’t think, because you can’t think of two pains at the same time.”
  • The same girl indicated self-harm was preferrable to talking directly about her pain or emotional state, because “…it’s difficult [to share] because I feel vulnerable, and…kind of naked. I feel stupid and embarrassed.”

The girls in this category report feeling left behind and abandoned. They no longer think anyone will listen or hear them. And if anyone does notice their pain, they think they won’t care. Their self-harming behavior and extreme risk-taking are ways of expressing their pain and distress that simultaneously mitigate that pain and act as cries for someone else to help them deal with that pain. Because girls in this category report early trauma, the study authors theorize that these girls re-experience their early trauma each time they engage in self-harm, and each time they engage in extreme risk-taking behavior.

How This Study Helps Treatment Professionals

Adolescence is a time of rapid change.

Mind, body, and emotions all transform dramatically in a period that’s relatively short, compared to childhood and adulthood. It’s a unique and critical time to offer support and help teens develop skills that will serve them well in adulthood.

Adolescence is also a time when humans begin to form an identity – a self – that’s separate and distinct from their parents. The lived experience of the girls in this study connects the experience of adolescent differentiation – i.e. identity formation – with the experience of self-harming behavior. In each of the superordinate themes identified by the researchers, the girls who describe these themes embody distinct examples of a maladapted concept of self: The Punished Self, The Unknown Self, and The Harmed Self.

Therapists can leverage their knowledge of adolescent identity formation and reconcile their therapeutic approach with the concepts of self that are exemplified by the nature of the self-harming behavior.

In other words, an adolescent girl living with and forming a concept of The Punished Self may benefit from a different approach than an adolescent girl living with and forming a concept of The Harmed Self, and an adolescent girl living with a concept of The Unknown Self may benefit from an approach to treatment that’s different from one appropriate for girls living with and forming The Punished or The Harmed Self.

What know treatment tailored to the specific needs of each individual has a greater chance of success than generic treatment. That’s how this information helps therapists: It helps them focus on the real internal lives of the girls they seek to support, and work to target the patterns of thought and behavior that cause the most harm sooner, rather than later.

How This Study Helps Parents

This information can help parents understand the why behind self-harming behavior. When a parent learns their child is in pain and doesn’t know how to express it, they typically do everything they can to remedy the situation. With regards to self-harm, the remedy – from the parent perspective – is unconditional love and understanding – supported by treatment and therapy delivered by a qualified, licensed, mental health professional.

To date, the most effective known treatment for teens who engage in NSSI is dialectical behavior therapy (DBT). This approach helps teens who need to learn to process overwhelming feelings and restructure maladaptive patterns of thought and emotion. These are the two skills teenage girls who engage in self-harming behavior need the most. To learn more about DBT, please read these articles:

Why Is My Daughter Cutting Herself? A Guide to Causes and Treatment

Self-Injury Treatment Programs for Non-Suicidal Teens

Finding Help: Resources

If you’re seeking treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.