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Self-harm behaviors in American youth rose sharply during the peak of the COVID-19 pandemic and continue to be a concern among counselors who work with children and adolescents. In early 2021, FAIR Health completed an in-depth analysis of insurance claim records to compare changes between 2019 and 2020. The New York City-based nonprofit found the mental health claims for individuals between the ages of 13 and 18 doubled between March and April 2019 and the same months one year later. That same age group saw a startling increase — nearly 100% — in the number of insurance claims for medical care received for intentional self-harm between April 2019 to April 2020. And the Northeastern United States (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont) saw the highest spike in claims for treatment of injuries in teenagers from intentional self-harm — a 333.93% increase — between August 2019 and August 2020. This data tracks with what many counselors are seeing in their own caseloads: An increase in young clients who turn to self-harm to cope with the stress and upheaval that came — and continues to come — with the COVID-19 pandemic. There is a strong correlation between social isolation and self-harm, notes Deanna Dopplick, a licensed professional counselor (LPC) at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury (NSSI) in St. Louis. As hard as it was for children and adolescents to have decreased connection with peers while schools were closed during the peak of the pandemic, it’s been equally challenging for them to return and reintegrate to the social dynamics of in-person school, she says. Dopplick, an American Counseling Association member, is among the many practitioners who are seeing an uptick in client referrals for self-harm among children and adolescents. Her organization has “struggled to keep up” with the need for services, she says, and unfortunately, many prospective clients sometimes end up on a waiting list. In addition to new clients, Dopplick says she’s also seen an increase in relapses among clients who have returned to self-harm behaviors to cope after making progress in therapy previously. As more counselors see youth who self-harm on their caseloads, Dopplick urges practitioners to focus on empathizing with these clients and fostering a trusting therapeutic relationship. The worst thing a practitioner can do, she says, is to panic or act fearful when a client discloses the behavior or dismiss it as attention-seeking. “I have seen clients that have been in therapy for months or even years [before coming to SAFE], and the behavior has been so protected and shameful that they haven’t disclosed it. There is a stigma that self-injury is weird or different or ‘crazy.’ It’s not something that’s easy to open up about,” says Dopplick, who provides individual and group counseling for clients 12 and older. “We [counselors] need to make sure we’re meeting the client where they’re at, humanizing them and validating their experience. … It [self-harm] is so much more common than people think, and it doesn’t make [the client] scary or different. Empathy goes a long, long way with these clients.”

A way to cope

Michael Visconti is a licensed mental health counselor who treats children and adolescents in private practice in Boston. He estimates that one-quarter of his caseload at any time is exhibiting self-harm behaviors — a proportion that rose to roughly 50% during the peak of the pandemic. Many of these clients are referrals for self-harm from a local pediatric medical office. The youngest client Visconti has counseled for self-harm behavior (in the form of intentional head banging) was six years old, but he finds it’s most common in younger teenagers, ages 12 to 15, he says. Like Dopplick, Visconti emphasizes that there is a “direct correlation” between social isolation, feelings of hopelessness and self-harm behaviors in youth. “The more isolated an individual is, the less they feel they can reach out to others and express that emotion, so they turn inward,” Visconti explains. “Most often, it’s a maladaptive form of coping.” While the intense isolation that occurred during the peak of the pandemic has lessened, all the same stressors that youth experienced before the pandemic (such as abuse, neglect or trauma at home, negative body image, social pressures and negative messaging on social media) remain, he notes. In Visconti’s experience, the reasons that drive youth to self-harm often fall into a few common categories:

• Managing emotions: When feelings are strong and uncomfortable, adolescents and young clients sometimes find it easier to experience physical pain rather than emotional distress. Self-harm offers an immediate and effective means of emotion regulation in the short term. Visconti says that in his experience, this is the most common pathway to self-harm.
• Communicating: Some individuals make use of self-harm to outwardly display their emotional pain because they don’t have the means or opportunity to put it into words. This can be especially common among youth who live in invalidating family and home environments, Visconti says.
• Punishment: Young clients sometimes turn to self-harm to punish themselves and “confirm” and internalize the negative narrative they have about themselves, Visconti says. These clients often believe that they are the problem and reason for their unhappiness, and self-harm is a way to reinforce these feelings. This is common among youth with poor self-esteem and/or a trauma history, he adds. Dopplick also finds that young clients who self-harm often struggle with intrusive thoughts that are intensely negative, such as “I am bad,” “There is something wrong with me” or “I am a disappointment,” so she spends a lot of time focusing on redirecting self-talk with clients at her program.
• Seeking control: Some young clients turn to self-injury as a means to exert control in their life, albeit in a painful way. It can be a maladaptive way to find autonomy, Visconti explains. This was the especially the case when many youths felt that the “fundamentals of their life had been stripped” away during the pandemic, such as the routine of the school day, social activities, extracurricular activities and other things they enjoyed.

Asking the right questions

The crux of what defines NSSI is the intent behind the behavior, Visconti explains. Self-harm can be an impulsive phenomenon as well as something that is very deliberate, planned and well thought out. Visconti says that it’s not uncommon for him to see young clients who have created a self-harm “kit” for themselves, complete with harming tools as well as items to disinfect and treat wounds afterward. When assessing for self-harm, counselors should not hesitate to ask clients directly about whether an injury was deliberate to determine intent, Visconti says. He often uses questions such as “Was that [injury] purposeful?” or “Did you place yourself in that setting with the hope that it harmed you?” That second question can help uncover behaviors that are beyond the common ones that counselors may think of, such as cutting or burning. For example, Visconti once had a young client who slept on a mattress that had a metal spring poking out of it, and he purposely didn’t tell the adults in his life about it because he hoped that it would cut and injure him while he was in bed. Asking questions about intent can also help uncover behaviors that a client has kept hidden or that escape the notice of peers or adults in a client’s life. Dopplick has also seen self-injury behaviors that are outside of what a counselor may expect. This includes keeping a (non-self-inflicted) wound from healing, hitting or biting oneself, inserting objects under the skin, ingesting things that the client knows are toxic or dangerous (such as glass or household cleaners), head banging, hair pulling, picking of skin or nails and other behaviors. In sessions, asking clients questions to determine the frequency and severity of self-harm impulses and actions is vital to understand the context of their behavior and level of risk, Dopplick says. For example, a client who has self-injured twice by a single method (i.e., rubbing themselves with an eraser to the point of burning) will need a different response than an individual who has injured themselves 100 times or uses multiple methods (e.g., cutting with a razor blade, punching walls). Understanding the full context of a client’s NSSI can help a counselor identify the reasons why they engage in the behavior and, ultimately, personalize and tailor treatment to meet their needs. Dopplick encourages counselors to ask clients a range of questions, including:

• Have they ever received medical attention for NSSI or needed attention but didn’t seek it?
• What tools are they using to injure themselves? Do they have access to these tools?
• How often are they engaging in self-injury?
• Are their harming behaviors usually impulsive or preplanned?
• Does anyone else, such as a parent or a friend, know that they’re self-injuring?

“Having the impulse to injure is different than following through with action,” Dopplick adds. “They may have impulses every day but may only injure once per week. It’s something to ask about: How are they managing their impulses?” She recommends counselors ask clients to keep a log to track situations when they felt the urge to self-harm or engaged in self-harm, which she says can be helpful in therapy because it can shed light — both for the client and the clinician — on patterns. Dopplick encourages clients to record what they were doing and feeling before, during and after an urge to self-injure to help identify triggers. Although NSSI is distinct from suicidality, the counselors interviewed for this article note that it’s important to assess clients who self-harm for suicidal intent because the two issues can sometimes overlap. Visconti uses the Columbia-Suicide Severity Rating Scale and recommends it as a helpful way to screen both for suicidality and self-injury and parse out the intent and severity of a client’s behavior. The tool’s questions can help determine how chronic a client’s behavior and feelings are, he explains, and it can be easily used with many different client populations and treatment settings. Discussing self-injury with a young client can be uncomfortable or worry-inducing for a clinician, Dopplick and Visconti admit. However, it’s vitally important for counselors to complete a thorough assessment to determine a client’s level of risk without becoming panicked and jumping to crisis response, such as talking about hospitalization. “If you [the counselor] seem scared or overwhelmed or go straight into crisis mode, you won’t get all the information you need from the client,” Dopplick stresses. And “that will make them very hesitant to disclose self-injury again.” She encourages counselors to keep an open mind when asking clients about their self-harm behaviors. Making assumptions about the factors that contribute or the reasons why they are engaging in NSSI “is the best way to shut down the conversation,” Dopplick adds. Instead, “see the client as the expert on themselves and their behavior. Do not criticize, minimize [the behavior], come off in a punitive way or assume they’re doing it for attention or because their friends are doing it,” she stresses. “Really put the client in the driver’s seat instead of coming at them with assumptions.”

Finding healthy ways to cope

At its core, NSSI indicates that a client has unmet needs, Dopplick says. A counselor’s role then is to help the client identify and understand those needs and find ways to meet them without turning to self-harm. “No one self-injures for no reason; there’s always an underlying reason, a function,” she notes. “For most clients, it [self-harm] is something that they’re hiding, something just for them, something that ‘helps’ them.” Dopplick says that the counseling groups she leads for self-injury spend the majority of the time talking about the context and circumstances surrounding their self-harm, rather than the actual behavior. For young clients, this often includes the pressures their parents put on them or stress related to school or social relationships. “We talk about the why and how more than the what,” Dopplick says. “The self-injury is not the actual problem; it’s what’s underneath it. All the underlying stuff — the why — is the problem, and [counselors] can miss the boat if [they] don’t explore it.” Paige Santmyer, an LPC who works with teens and adults at a Christian counseling practice in the Atlanta area, agrees that helping clients identify what triggers their urge to self-harm is an important first step, followed by creating a plan to replace the behavior with healthier options. It also helps to identify the perceived “reward” they seek in self-harm, she says, to tailor a client’s treatment plan and coping mechanisms. For example, if a young client struggles with feeling numb and turns to cutting themselves to feel something, Santmyer says she would teach the client mindfulness and guided imagery techniques that can help them connect to how they’re feeling. Or, depending on the client, they might respond to something creative such as using virtual reality to “go” hiking or zip lining to redirect and energize themselves, she suggests. Young clients will need activities and techniques at the ready to replace the urge to self-harm; planning ahead is key. Santmyer brainstorms with clients to identify ways they can seek connection and soothe themselves when needed, such as doodling or drawing or talking to an accountability partner. She also finds it helpful to have young clients create a “distraction box” filled with special or favorite items that can help to self-soothe and take their minds off the urge to self-harm. These items can include art, knitting or crochet supplies, essential oils, a favorite lotion, coloring or puzzle books, pictures of loved ones, an object with beads for counting or a kaleidoscope to look through. (For more on creating self-soothing kits with clients, read the Counseling Today online exclusive “Regulating the autonomic nervous system via sensory stimulation.”) Similarly, Visconti says he focuses on helping young clients who self-harm find ways to redirect themselves away from the urge to injure. He gives clients a worksheet with 100+ ideas from Matthew McKay, Jeffrey Wood and Jeffery Brantley’s The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance to spark ideas and keep for future reference. Depending on the client’s age and needs, activities could include playing video games, visiting a friend, eating their favorite flavor of ice cream, writing a song, using an app to learn a new language, getting a haircut or painting their nails.

Managing distressing emotions

The counselors interviewed for this article agree that while clinicians need to tailor their work to fit their clients’ individual needs, many young clients who self-harm will need some combination of treatment that challenges negative self-talk and strengthens distress tolerance and emotion recognition and regulation. Santmyer says that it’s common for young clients who struggle with NSSI to be disconnected from and confused about their emotions. She focuses on emotion recognition with clients by asking them to think about where they feel strong emotions in their body and prompting them to talk about what it feels like and how they usually respond to those sensations. She also finds cognitive behavior therapy (CBT) helpful to guide clients to explore, challenge and reframe the fears and negative core beliefs that drive feelings such as worthlessness or perfectionism that trigger an urge to self-injure. “Helping them understand and name the emotion they are feeling helps clients feel more in control of themselves instead of feeling compelled to manage the sensation itself through self-injury. Counselors can also use CBT to build insight into how emotions are giving them messages, how they can interpret them in positive or negative ways, and how those interpretations lead them toward or away from self-injury,” explains Santmyer, an ACA member. “Ultimately, clients will need to understand how they are perpetuating their self-injury cycles and practice changing their negative thoughts to change their self-harming choices into more thoughtful and healthy responses.” Santmyer and Visconti also noted that dialectical behavior therapy (DBT) can be especially helpful to use with young clients who self-harm because of its focus on emotion regulation and distress tolerance. (Santmyer and Visconti are not certified in DBT but have studied it and draw from the method in their work with clients.) DBT is a good fit for this client population because it’s practical and effective in a short amount of time and it teaches much-needed skills and coping mechanisms to manage stress and tolerate uncomfortable feelings, Visconti notes. In fact, he says he’s seen DBT techniques spark growth and healing in self-harm clients right away because of the skill-building component. However, DBT is most helpful for clients who self-harm as an emotional outlet, rather than those who use the behaviors to communicate or exhibit their emotional pain, he adds. Santmyer finds that the ACCEPTS skill from DBT is particularly helpful to strengthen clients’ ability to overcome distressing emotions and situations without turning to self-harm. This tool guides clients to think about or engage in:

• Activities: Do something that requires thought and focus, such as writing in a journal, to shift their attention away from distressing emotions.
• Contributing: Do something that involves focusing on other people (e.g., sending a card, asking a loved one about their day, doing volunteer work).
• Comparisons: Put their situation in perspective by comparing it to something more painful or challenging, including thinking of a time when they were in greater distress and got through it.
• Emotions: Find a way to disrupt the emotion they are feeling (e.g., angry, sad) and replace it with a different or opposite emotion (e.g., going for a walk to calm oneself, watching a happy movie).
• Pushing away: Use a technique such as guided imagery to block painful feelings from their mind and delay the urge to self-harm.
• Thoughts: Use a strategy to shift one’s thoughts to something neutral (e.g., counting backwards, reciting song lyrics, naming objects around them that start with a certain letter of the alphabet).
• Sensations: Engage in activities that trigger safe sensations that distract them from distressing emotions (e.g., eating something spicy, feeling the water on their body during a shower).

Trust and validation

Getting to know the client and tailoring treatment to their individual needs must take priority when counseling youth who struggle with NSSI, Dopplick says. She suggests that practitioners first find ways to connect with clients — particularly those who have been referred to counseling specifically for NSSI — and talk about topics other than self-injury to forge a trusting relationship. Believing the client and validating their experience and pain should be the counselor’s No. 1 priority, she stresses. Only then can a counselor begin to identify and delve into the reasons underneath their self-injury. “Often [these clients] feel that no one understands or validates their pain, and they are compelled to continue self-harming as a way to express in their body what they feel they cannot express verbally,” Santmyer says. “The validation and compassion of the therapist will bring the safety that young clients need to explore the drivers of self-harm.” Dopplick finds that she’s sometimes the first adult to tell a young client that she understands why they are distressed to the point of needing to self-harm or to emphasize that they’re not weird or “crazy” for engaging in NSSI. After validating the client’s experience, she explains that she can help them find other ways to cope. It’s vital for counselors to keep an open mind and accepting demeanor with these clients, Dopplick stresses. “There’s a huge difference between expressing your concern in a caring way, rather than asking 1,000 questions and focusing on” a client’s self-harm behaviors, she says. “It’s important to approach it with curiosity. … They know themselves and know what this behavior does for them; you just have to help them figure that out, and then build off of that to get more information.” When working with young clients who self-harm, Visconti says he makes sure to acknowledge how hard it is to disclose and discuss such a painful and deeply personal topic. He thanks them for trusting him with such vulnerable information and feelings. “I empathize [with clients], commiserate and then try and bring about a sense of hope and preservation,” he adds. The most important technique a counselor can use with these clients is the therapeutic relationship itself, Visconti says. He admits that young clients who engage in self-harm can be challenging, not only because it’s an uncomfortable topic to address but also because they often have multiple presenting concerns or mental health challenges. However, he pushes back against the misnomer that talking about self-harm in therapy can increase the behavior, retraumatize or cause emotional harm for a client. Counseling involves delving into many different types of painful topics, he says, and the key is for practitioners to handle it with openness and warmth. “The long-term benefits greatly outweigh that distress,” Visconti emphasizes. “It’s so crucial to the betterment of their client, and you’re not going to increase the likelihood [of NSSI] by talking about it — it doesn’t work like that.”

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Challenges that can co-occur with nonsuicidal self-injury

Depression and anxiety are the most common diagnoses that can co-occur in young clients who engage in nonsuicidal self-injury (NSSI). However, there are many other challenges that individuals may struggle with simultaneously. There is a high correlation between NSSI and eating disorders, as well as clients who have experienced trauma, particularly sexual trauma, as self-harm can be a way for these individuals to seek control, disconnect or cope with painful feelings, trauma flashbacks or the stress of continuing to live in an abusive environment. It also can co-occur with obsessive-compulsive disorder in clients who use self-injury to satisfy urges for repetitive behaviors to manage or communicate distress. This can also be the case for individuals with autism. “It’s very effective to disconnect: To disconnect with their brain, with their body and overwhelming feelings, and this [self-injury] gets it to stop. But that’s also one thing that makes it hard to stop doing,” says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for NSSI in St. Louis. “A lot of people think of self-injury as this impulsive thing, and it can be, but it also can be very obsessive. If they [a young client] can’t manage their stress at school, they may be thinking all day about injuring once they get home.” The relief and other satisfactions that an individual seeks from self-harm lessen over time, which sometimes causes individuals to increase the self-harm behaviors and, eventually, turn to other risky behaviors, such as sexual promiscuity, restrictive eating or using substances, to seek similar feelings of reward or relief. So counselors who work with clients who disclose self-injury behaviors (or a past history of NSSI) should also screen for substance use, suicidal ideation, eating disorders, behavioral addictions and other high-risk or destructive behaviors. This information came from an interview with Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives (selfinjury.com).

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Supporting parents of young clients who self-injure

Counselors who work with children or adolescents who self-injure are in a position to offer support to adults in the client’s life who are misunderstanding or anxious and upset about the child’s behavior. Understandably, parents often panic and experience intense worry when they find out their child is self-harming, says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury in St. Louis. Often, parents’ first response is to enact punishment, such as taking the child’s cellphone away to cut off contact with friends or locking up all the sharp objects in the home. However, this won’t stop the child’s self-harm behavior — it can actually increase it, Dopplick says. A punitive response from the adults in a client’s life will only cause the child or adolescent to feel even more shame about their self-harm, and it can lead them to engage in harming behaviors that are more hidden and secretive. This includes injuring themselves in ways that won’t leave a mark or on parts of the body that are usually covered by clothing. It’s also not helpful for parents to reward a child for going a length of time without injuring themselves, she adds. Counselors can offer psychoeducation to parents on why the punishment-reward cycle is not effective in situations of self-harm, and they can provide healthier alternatives. “We have to remember that it [self-harm] is a coping mechanism. It’s not a healthy one, but it does not mean that the child is ‘bad,’” seeking attention or acting out, Dopplick stresses. She finds that the book Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones by Janis Whitlock and Elizabeth Lloyd-Richardson is a helpful resource to recommend to parents. The book offers guidance on ways parents can talk to their child about self-harm and support them in a healthy way. (Whitlock, one of the co-authors, is the director of the Self-Injury & Recovery Resources research program at Cornell University; Dopplick notes that Whitlock’s entire body of research can be helpful to counselor practitioners who want to learn more about the topic of self-harm.) Parents often jump to the assumption that self-harm behaviors mean that their child is suicidal, says Michael Visconti, a licensed mental health counselor who treats children and adolescents in private practice in Boston. Research indicates that the majority of individuals who self-harm do not have suicidal thoughts, he notes. So counselors can educate parents on the differences between suicidal ideation and self-injury and assure them that although self-harm behaviors are concerning, they don’t necessarily mean that their child wants to end their life, Visconti stresses.

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Bethany Bray is a former senior writer and social media coordinator for Counseling Today.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.