Therapy For Girls Who Are Self-harming

Article three in a series of three about self-harm.

Self-Harm is an increasingly pervasive symptom of emotional distress among adolescent girls. Because it involves physical damage to the sufferer, cutting understandably evokes distress and fear in others. Viewed on a continuum, self-harming behavior can easily—though not always accurately—be interpreted as a precursor to suicidal behavior. Because self-harm is so pervasive and so disturbing, InnerChange program director Dustin Tibbitts, LMFT, has written a three-part series to help parents better understand and address this behavior.

Physical Safety

To provide effective therapy for an adolescent struggling with self-harm, the first step is to make the home and school environment as safe as possible. Through situational planning, we can remove or lock up objects that are too readily available for self-harm, such as shaving razors, kitchen knives, utility blades, and so forth. Some parents find that routine, unexpected room searches or body searches work. It is wise to remove as many sharp objects as possible, understanding that adolescent self-injurers will harm with whatever is around. Tiny screws in the light switch, a stray staple in the carpet, jagged rocks, and the sharp edges of construction paper all can be used for self-harm.

It is, of course, impossible to remove all of these from a home or school. So why try? Because therapists, parents and other caregivers send a message of compassion and concern when they remove the obvious, easily-accessible objects. We communicate that we are fully committed to the healing process, and we model safety in our physical surroundings. It sets us up perfectly to move into the most important part of therapy for self-harm: a nurturing, safe relationship.

Love and Connection

Parents are often so scared by their adolescent’s self-harm that they overreact. When parents overreact, they inadvertently shame their already ashamed child. Their assumption is that their child is going to take the “next step” and commit suicide. It is important to know that self-harm does not always lead to suicidal behavior, and that projecting fear and shame can make the problem worse. A response that is calm, loving and curious is a more productive way to engage an adolescent who is struggling.

For some girls cutting is a cry for someone to show compassion toward them. For these girls, psychotherapist and author Steven Levenkron writes, “talk, trust, healthy attachment, intimacy, and secure communication are the necessary building blocks for change.” He is quick to point out that “the prerequisite for the helper is to develop influence with the self-mutilator” and that influence comes from experiencing a trusting, safe relationship. This is the foundation which parents and therapists must lay before healing can begin.

On their webpage dedicated to eliminating self-harm through education, the Mayo Clinic advises adolescent self-harmers that “expanding social networks” is a great way to help mitigate self-harm. Why is this? Because connection with other human beings is the primary way for adolescent girls who hurt themselves to reduce shame, feel valued, and fill time with healthy activities.

Other female adolescent clients of mine have found comfort in sharing their anxieties with a trusted friend. Having immediate access to their “self-harm Sponsor” at any time was a key to healing. Texting, Facebook, email, and cell phone calls make their friendships accessible and immediate. Additionally, the advent of social networking technologies, such as Twitter, make an entire group of healthy friends immediately accessible with a simple text message via cell phone.

Re-establish Identity and Worth


Many young people’s self harm is a manifestation of a deeper identity crisis. Adolescents struggle anyway with knowing who they are, but this is an even more difficult dilemma for teens engaged in cutting. Self-injury for these adolescents isn’t just a part of them, it comes to fundamentally define their sense of self.

When a therapist or parent helps a young woman reconnect with her core identity, especially who she was as a child growing up, it can be a powerful entry point for effective therapy and can help correct the problem. Often, the pain with which she is trying to cope has blinded her to any positive events in her past. Scrapbooks, photographs, and stories about her can be touchstones she can return to when she forgets who she is or is confused by the turmoil that the immediate pain causes in her life.

It’s not only identity which suffers when girls are in pain. The pain threatens their sense of self-worth. At her core, she begins to lose hope in the value she brings to the world and her family and friends. She loses touch with the infinite part of herself – the part which cannot be measured and which is invaluable.

Treating self-harm requires us to see beyond the surface. We can never help a young woman heal if we don’t acknowledge the true nature of the problem, as well as its scope. That said, it is important to remember that the problem may appear imposing and intractable, but it is critical that we communicate to her that, with help, nothing is impossible to overcome.

Personal Agency

As therapists and parents, our job is to influence adolescents in our care to make good decisions, not to manipulate, shame, or control them into more positive behavior. We can become so anxious for the welfare of our clients and daughters, that we unthinkingly trade our respect for their individual agency for our need to reduce our own anxiety for their safety. At times like this, it’s important to remember that the only control we have over any human being, including our own children, is the power of persuasion that exists within our relationship with her. Our relationships should be built on alliance, not compliance.

Authoritarian forms of relationship will eventually produce the opposite of what we want. Why do I state this so strongly? I’ll give the most simplistic example: when the young woman leaves our presence, our immediate influence ends. Once she’s alone, she might think twice about hurting herself only if she has respect for someone else, wants to do the right thing, and cares that someone will be devastated if she hurts her body

The relationship is all we have.

JoAnna, a 14-year-old who carved words like “HATE” and “PIG” on the inside of her thighs said,

“I think one of the most important dynamics in a self mutilator’s treatment is to make sure they are aware that thoughts of cutting will linger for a long time, but refusing to act on those impulses is what matters most. As with most self destructive behavioral patterns, there are no means by which to end a person’s harmful activities – short of locking them up in a padded room, etc. I strongly believe that only the conscious intent of a patient to cease whatever harmful activities they have engaged in will end abusive patterns to the self.

“Though honestly and openly seeking the true nature behind masochistic acts can aid in a person’s therapy, the ultimate responsibility for change towards emotional betterment rests squarely upon the shoulders of the patient – once they realize their actions no longer (if ever) serve a useful purpose. A decision coming from within to stop negative behavior, without external influences, is considerably more potent and therefore has a higher chance for success and perpetuation.”

It’s important to emphasize to young women that they have control of themselves. Especially in our society today, when so many young girls are taught to ignore their instincts, their inner-voice, girls need a trusted adult to validate their competence.

If we try to “fix” things for a young woman – to do more or work harder than she works, we inadvertently communicate that she is incapable. We reinforce what she desperately wants not to believe.

Every act, every word we utter must assert our confidence in her ability to heal her own pain. Drowning her distress and doubt, she must be brought back to the surface for a gulp of clean air; we must help her breathe in her own resourcefulness. In this way, she will never confuse her success with our help. She will view her success as she should – as her own.

Alternatives to Self Harm

What I am about to write next is something none of us like to hear.

She will harm herself again. It’s not over. She will lapse back into the familiar, destructive behavior.

Knowing this, it is imperative that therapists and parents provide other options for adolescents who are hurting themselves, yet have expressed a desire to stop. New habits and new coping skills provide a line of defense against self-injury, especially when the girl is feeling lonely. One former client, Melissa, said:

“I know it helped me to learn other coping mechanisms and use them. Find other ways to get out your feelings, a way that works for you. Some people like talking. Some like music or art, journaling, etc. You have to find what works for you. And a lot of times it doesn’t feel as good as cutting, which may seem like the best quick fix, but if you get through to the person that in the long run it makes problems worse, then getting through it in a different way is more acceptable.”

A few ideas for “replacement activities” to get your imagination going include:

  • Deep breathing
  • Relaxation techniques
  • Call a friend, your therapist or a crisis line
  • Try not be alone (visit a friend, go shopping, etc.)
  • Take a hot bath
  • Listen to music
  • Go for a walk
  • Write in a journal

So, we have established a physical environment that is safe. We have a healthy, affirming relationship with the adolescent. She trusts us enough to show her therapist and/or parents her scars and tell us how, when, and why she cuts. She explores the deeper issues that plague her. She is able to see value in her life. She expresses a desire to change and has proven, through a series of recent choices, that she means to follow through on her newfound commitment to life. And we’ve provided her with new options that work for her.

There’s hope!