Evidence-Based Treatment for Teens Who Self-Harm

Self-cutting – known among mental health experts by its clinical name, non-suicidal self-injury (NSSI) – can be difficult to understand for someone who’s never engaged in or known anyone who’s engaged in the behavior.

The first person most people ask themselves is “Why?”

That’s the most common question parents ask when they learn their teen engages in this type of behavior. We’ll address that question and offer an answer in a moment. First, we want to answer the second question most parents have when they learn their teen engages in self-cutting, self-mutilation, other forms of self-harm. It’s actually a series of questions:

Is there treatment for self-cutting?

Are there self-harm treatment centers?

Is self-mutilation disorder the same thing as cutting?

Are there specialized self-harm treatment programs for teens?

The answer to all these questions is yes:

There is treatment for self-cutting.

Most adolescent treatment centers can also be considered self-harm treatment centers, since most offer treatment and support for teens who self-harm.

Self-mutilation disorder and self-harm, self-cutting, and self-injury are all names for the same host of maladaptive behaviors.

Specialized self-harm treatment programs for teens do exist.

However, the phrase self-mutilation has not been in use by clinical professionals since the 90s. Around 2000, when the first research on self-harming behavior appeared, clinicians realized they needed to specify the name of the disorder. As mentioned above, the official diagnosis for self-cutting is non-suicidal self-injury (NSSI). The name is important because – although NSSI increases the risk of later suicide attempts – in most cases, people who engage in NSSI do not intend to die.

That brings us to the first question we posed. The one that most people – parents of teens who engage in NSSI in particular – ask when they hear about cutting, self-cutting, and self-mutilation:

“Why?”

We will answer that question. But before we do, we need to define what we mean when we say self-cutting, self-harm, and NSSI.

What Exactly is Self-Harm?

To understand the why behind self-cutting, self-harm, and NSSI, we need to understand the what.

The  American Psychological Association (APA) offers this clinical definition:

“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.”

We need to distinguish between self-harm and self-injury since mental health professionals identify important functional differences between these two behaviors. Self-harm is a broad category that includes risky behavior, eating disorders, and addiction disorders. In contrast, clinicians define NSSI, self-cutting, and self-injury as a subset of behaviors under the self-harm category. However, laypeople and clinicians alike often use both terms – self-harm and self-injury – when discussing NSSI.

That’s a reliable, clinical explanation of what NSSI is.

Now we’ll discuss why teens engage in NSSI behaviors like self-cutting.

Why Do Teens Self-Harm?

To define and explain the why behind self-cutting and NSSI, we’ll refer to a paper published in 2018 called “A Meta-Analysis of The Prevalence of Different Functions of Non-Suicidal Self-Injury.” We use this reference because it’s the only existing meta-analysis (a paper that summarizes the findings of all relevant publications on a topic) that explores the various functions individuals who engage in NSSI assign to NSSI. The paper also reports prevalence data on the various reasons behind self-cutting behavior – meaning what percentage of people who self-harm do so for which reasons.

Study authors define two primary reasons people engage in NSSI (self-cutting, self-harm, self-mutilation): intrapersonal and interpersonal. Intrapersonal means “…factors operating or constructs occurring within the person, such as attitudes, decisions, self-concept, self-esteem, or self-regulation,” while interpersonal refers to “…actions, events, and feelings between two or more individuals…such as the ability to communicate thought and feeling or to assume appropriate social responsibilities.”

A simple way to think of this is that intrapersonal reasons mean a teen engages in self-cutting for personal reasons that exist within themselves, whereas interpersonal reasons mean a teen engages in self-cutting for reasons to do with other people.

Let’s explore the intrapersonal and interpersonal functions – i.e. the reasons why – people engage in NSSI. Here’s what the study authors report:

The Functions of Self-Harm, Self-Cutting, and NSSI

• Intrapersonal (66-81% of people who engage in self-harm):
  • Emotional Regulation:
    • Escape a negative mental/emotional state
    • Induce a positive mental/emotional state
  • Self-punishment
• Interpersonal (33-56% of people who engage in self-harm):
  • Communicate distress
  • Influence others
  • Punish others

These prevalence rates are important because the dominant mode of thinking around NSSI has been that most people who engage in NSSI do so for intrapersonal reasons, i.e. to regulate and process uncomfortable or painful emotions. This paper shows that, while the percentage of people who self-harm for interpersonal reasons is smaller than those who engage in self-harm for intrapersonal reasons, the percentage is significant. Both parents of teens who self-harm and clinicians who treat them should understand that teens self-harm not only to regulate internal emotions but to communicate their level of distress to others.

Next, we’ll talk about how a mental health professional determines what level of care is most appropriate for teens who self-harm.

Self-Cutting Teens: How Professionals Determine the Right Level of Care

We’re sure you know this, but we need to say it anyway: an article like this does not replace, stand in for, or otherwise supersede a treatment recommendation made after a full psychiatric assessment administered by a mental health professional. What this article can do is share information about outpatient treatment, inpatient treatment, and hospitalization – a.k.a. three specific levels of care – and discuss the criteria mental health professionals might use to recommend one level of care over another.

There’s something else you need to know:

If your teen is in crisis right now, meaning they’re in imminent danger of harming themselves or others, take them to the emergency room at a hospital, call 911, or take them to an adolescent mental health treatment center or psychiatric hospital that offers emergency support for teens engaging in NSSI.

Now we’ll talk about which level of care might be appropriate for your teen.

A mental health professional will determine the appropriate level of care for your teen based on three primary factors:

• Symptom acuity: how immediately serious their symptoms are now
• Symptom severity: how intense and disruptive their symptoms are now
• Treatment history: teens who have engaged in treatment previously, without success, might begin in a different place than a teen who has never engaged in treatment

The prime concern is safety. Teens who present a danger to themselves or others require an immersive level of care, while teens who are not an imminent danger to themselves often do not require an immersive level of care. Teens in crisis are most often considered high-acuity with severe symptoms, while teens who are not in crisis are most often considered low-acuity with moderate symptoms. But again, for practical purposes for your teen, the official word on those distinctions belongs to qualified professionals, not this article.

Levels of Care for Self-Cutting Teens: Outpatient Treatment, Inpatient Treatment, or Hospitalization

We’ll discuss these three levels of care, in order from least immersive to most immersive, beginning with outpatient treatment.

Outpatient Treatment

When your teen participates in outpatient treatment, you take them to an office one or two times per week. Outpatient treatment is the typical starting point for a teen who self-harms but has low acuity and symptoms of moderate severity. For teens who self-harm, but can function at school, at home, and with peers, a therapist may recommend outpatient treatment.

Inpatient/Residential Treatment

When your teen participates in an inpatient/residential program, they receive a more immersive level of support and care than in an outpatient program. These programs occur at Residential Treatment Centers, known as RTCs. Also, it’s important to understand that broadly speaking, inpatient treatment means your teen lives on-site at the treatment facility 24/7 while they receive treatment. That’s why residential treatment programs and hospitalization programs are both, technically speaking, inpatient levels of care.

We’ll talk about hospitalization next. Now, more information on residential treatment.

Compared to outpatient treatment, residential/inpatient treatment programs allow your teen more time for targeted therapy to help them manage their NSSI behaviors. In an RTC program, your teen will learn and practice coping skills and distress tolerance techniques that help them process their emotions without harming themselves. They have the opportunity to practice what they learn with direct support from clinicians and peers. The time they take learning about their disorder and practicing practical skills prepares them to step down to a less immersive level of care, such as outpatient treatment.

Psychiatric Hospitalization

Hospitalization is the most immersive level of treatment and care for self-cutting teens. Hospitalization treatment programs typically occur in the psychiatric ward of a general or specialized psychiatric hospital. If you admit your teen to a psychiatric hospital, a team of psychiatrists, therapists, and/or psychiatric nurses monitor them around the clock. Movement within a psychiatric hospital is restricted and controlled. Doors between living spaces, dining areas, and shared spaces are typically locked when not in use for designated purposes.

Hospitalization may be appropriate for your teen if they’re in immediate crisis, diagnosed as high acuity with severe symptoms, previously attempted residential treatment, or previously attempted suicide. In addition, it’s important to understand that rules in psychiatric hospitals often allow staff to use direct physical contact in crisis situations. Most adolescent RTCs, though, have policies that prevent direct physical contact during emergencies. The terms most often used to describe these different policies are hands-on and hands-off, respectively.

How Do You Decide What Level of Treatment for Self-Cutting is Appropriate?

If you need to find a self-harm treatment center for your teen, you don’t have to do it alone. You make the final decision, of course, as with all things related to your teen. In the case of psychiatric care for teens who self-harm, though, you’ll have support as you go through your decision-making process.

Your go-to support system is the group of people you’ll come to know are your teen’s treatment team.

The professionals on the treatment team will be your teen’s primary care provider, your teen’s current psychiatrist, therapist, or counselor, and the clinical staff at the adolescent treatment center where your teen receives their full assessment and evaluation. When you decide on a treatment facility or location, the clinical staff there become part of your teen’s treatment team.

You, your teen, your family, and any relevant friends or caregivers will collaborate with the treatment team on the decision about what level of treatment your teen needs. As we mentioned above, if your teen is in immediate crisis, you can expect a mental health professional to recommend hospitalization. Your family group will make the final decision on that step.

You’ll make decisions about outpatient treatment and inpatient/residential treatment in the same manner. A licensed professional will make a recommendation based on their evaluation. Then you’ll talk things over with your family and your teen and finalize a plan that meets your family’s needs.

We’ll leave you with one last message: treatment works. Your teen can learn to manage their symptoms and behaviors in healthy and productive ways. They can learn the skills they need to process their emotions without harming themselves. Treatment can help them find balance in their life, create a new set of coping mechanisms, and look toward the future with hope and optimism.

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.