Self-harm in adolescence is, in most cases, an attempt to survive a feeling rather than an attempt to end a life, and getting that distinction right is what makes a useful response possible. [klonsky-2014-functions] It is also a serious signal that something has become unmanageable, and previous self-harm is the strongest single predictor of later suicide, so neither alarm nor dismissal is the right register. [hawton-2012-selfharm] This guide covers what drives it, how to recognise it, what to say, and what reduces it.
This article deliberately contains no description of methods. If you are looking for that, it is not here, and there is a better use of the next ten minutes further down.
What it is usually doing
Young people asked directly why they self-harm give a consistent set of answers, and almost none of them is what adults assume.
The most common is emotional relief: a feeling has become intolerable and this brings it down fast. The second is the reverse, interrupting numbness or dissociation with sensation, which is what “I wanted to feel something” means. The third is self-punishment, which travels with shame and with low self-worth. A smaller set of functions is interpersonal: making invisible distress visible, or communicating something that has not been heard.
Klonsky and colleagues summarise this evidence and the central point is that it works. [klonsky-2014-functions] The relief is real and it arrives within minutes. That is not a reason to be relaxed about it; it is the explanation for why it repeats, and it is the reason that asking a young person to stop, without offering anything that does the same job, is asking them to go back to the feeling with nothing.
The emotion-regulation account of self-harm described by Klonsky and colleagues (2014), in which distress falls sharply and secondary shame rises afterwards. Values illustrate the shape of that cycle rather than reporting measured scores.
The shame line is the part adults tend to miss, and it is why a response that adds shame makes the next episode more likely rather than less.
Recognising it
Most young people conceal it, so what you are usually noticing is the concealment rather than the thing itself.
Signs worth attending to: covering arms or legs in weather that does not call for it, unexplained injuries with explanations that do not quite fit, withdrawal from friends and from things that used to matter, a change in mood that has lasted weeks, sleep that has come apart, and a sudden interest in privacy that is out of character for that particular young person.
None of these is diagnostic on its own, and adolescence produces most of them for entirely ordinary reasons. It is the cluster and the change that matter.
The first conversation
What you say in the first minute has a larger effect than anything you plan afterwards, because it determines whether there is a second conversation.
Manage your own reaction first. Shock, anger, crying and rapid-fire questions all deliver the same message, which is that this is too much to be told about. Young people describe a parent’s distress as one of the main reasons they stopped disclosing.
Say something short and warm. “Thank you for telling me. I am glad I know. We will work this out.” You do not need a plan in the first minute and trying to produce one usually makes it worse.
Ask what it does, not why. “What does it do for you?” is answerable. “Why would you do that?” is not, and is heard as an accusation however it is meant.
Do not ask for a promise to stop. It will be given, because they want to reassure you, and it will not be kept, and then they have broken a promise as well, which adds to the shame that was already the problem.
Do ask directly about suicide. Asking does not plant the idea. Not asking leaves you guessing about the one thing you most need to know.
What reduces it
Interventions that teach an alternative way of handling intense emotion have the strongest support. Witt and colleagues reviewed psychosocial interventions for self-harm and found the clearest evidence for approaches of this kind, particularly dialectical behaviour therapy adapted for adolescents. [witt-2021-cochrane]
The logic is consistent throughout: the behaviour is serving a function, so treatment supplies a different route to that function rather than only removing the current one. Distress tolerance skills for the peak, emotion regulation skills for what builds toward it, and work on the relationships in which the distress often sits.
Alongside therapy, two practical things matter. Reducing access to means reduces harm in the moments when the urge is at its highest, and it is worth doing quietly rather than as a confrontation. And any underlying depression or anxiety needs treating in its own right, since self-harm frequently sits on top of one of them. [nice-2022-selfharm] Our guide to depression covers the most common one, and the depression screener takes a few minutes.
For a parent or carer: what to raise
A prompt for what to describe at an appointment, not a test, and it cannot assess risk. If you are worried about immediate safety, that is an emergency and not a checklist.
0 of 7 ticked
This is a pattern that needs assessment soon rather than watching for longer. If the last item is present, treat it as urgent.
Describe these specifics to a doctor rather than a general sense that something is wrong. Bring the list; it is easier than remembering under pressure.
Little of this is present. The most useful thing remains being someone who reacts calmly, which is what makes disclosure possible later.
No self-harm screener is published on this site, and self-assessment is the wrong tool for risk. The depression screener is here because low mood is the most common thing underneath.
When to seek help
Speak to a doctor if you have found out that a young person is self-harming, whatever the apparent severity, because previous self-harm is the strongest predictor of later suicide and that is true even when a particular episode had no suicidal intent. [hawton-2012-selfharm] Ask for an assessment rather than reassurance. Do not wait for it to happen again, and do not wait to see whether it stops on its own.
If there is any indication that a young person is thinking about ending their life, or if an injury needs medical attention, treat it as an emergency. Contact your local emergency services or a crisis helpline.