It was encouraging! To see the outpouring of articles, posters, blogs, tweets, campaigns and seminars on World Mental Health Day 2018. It’s a revolution we are all witnesses to! This year has been one of so many sea changes- The Mental Health Act 2017, Abolishing of Sec 377, and finally the start of the #MeTooIndia movement. People are finally talking about mental health more openly, sharing their stories and not ashamed to seek help.

This year’s WHO theme for WHMD “YOUNG PEOPLE AND MENTAL HEALTH IN A CHANGING WORLD”, was also heartening as it focusses on one of the most burning issues of our time. The youth is our hope for the future, and is unfortunately also the most stressed age-group today. Teens have been a special group for me personally as a therapist. My intuitive understanding of their issues, ability to build trust with them and work with them successfully  gives me first-hand awareness that this population is highly misunderstood and needs a huge amount of support. Let’s join hands to be there for our teens and young adults as they learn to adapt to this rapidly changing world.

10th October morning began on a great note. Apart from enjoying the many posts on social related to mental health awareness, I spoke on radio FM Ishq104.8 to the effervescent RJ Sangy on Teen Mental Health and the MeTooIndia movement. We spoke on sex education for teens, teen mental health, sexual harassment and how to be sensitive as a society towards those who disclose sexual harassment.  Here are the audios:

 

Last week, I had also worked hard on an article on teen self-harm for the wonderful online platform, Patients Engage, This vibrant portal supports a wide range of Wellness and Mental Health Awareness issues and it was so encouraging to see my article, WHY DOES A TEENAGER SELF HARM? published on World Mental Health Day. Teen self-harm is not a topic many want to talk about, especially in the media. However, the more silence we keep around this issue, the more dangerously close we are getting to mental health disaster among our youth. Since a large portion of my work as a therapist is with self-harm and suicide, this article was written from my experiences working with teens and parents in therapy. It can be shared by you, the readers as a guide for the community. Here it is:

WHY DOES A TEENAGER SELF HARM?

Myra, a bright Std 11 student, had begun withdrawing from her parents and friends. When she insisted on wearing long-sleeved outfits in the humid heat of Mumbai, her mother suspected something. Myra then showed her mother the cuts on her wrists. Her mother was at first shocked and then admonished Myra for being secretive.

19-year-old Anu’s boyfriend confessed he was having an affair and was most likely to break up with her. Anu said she needed to take a smoke and gather her thoughts. Her boyfriend heard a muffled scream, rushed to the balcony and found that Anu had used the cigarette to burn herself. Her boyfriend stormed out of the house calling her a “blackmailer”

Priya, a first-year student was feeling so low that she couldn’t wake up in time for college again today. Her parents yelled at her while leaving for work saying she was playing with her career. Priya went to the toilet, found a razor blade and cut herself. Frightened, she sought out her sister for help. Her sister yelled at her that she was an attention-seeking troublemaker.

What’s common in these stories?
Well, for one they are all based on real-life incidents. And second, these teens felt judged and demeaned, instead of understood and supported, when they sought help for self-harm. These youngsters are likely to feel shame and fear about these behaviours. The discomfort then feeds the problem, which means they are likely to hide any future self-harm from others and delay the process of getting help.

What is Self- harm?
Self-harm, also called non-suicidal self-injury (NSSI) is intentional physical self-injury without an intent to die. It includes various methods such as cutting, burning, scratching, beating oneself (head-butts, punches), biting, interfering with wound healing, reckless sex and eating to be sick.
Donald E. Greydanus and Helen D. Pratt write in the Psychiatric Times (2015) that the Worldwide prevalence of deliberate self-harm (DSH) among adolescents ranges between 6.2% and 46.5% and appears equally prevalent across sexes, ethnicities, and socioeconomic statuses. Closer home, India’s teen population is an extremely vulnerable group today. Evidence comes from a 2017 report by WHO titled “Mental health status of adolescents in South-East Asia”: which found that 25% of Indian students admit to feeling depressed. Following this report, the Health Ministry (‘India: Health of the Nation’s States 2017’) released a nation-wide study stating that the leading reasons for injury burden among the youth is suicide and self-harm. Therefore, it is necessary that we begin talking openly and frankly about the issue of self-harm; neglecting to do so will only ensure it remains a taboo subject, leaving a growing number of teenagers with few avenues of support and left to suffer in silence.

Why do teens self-harm?
Let’s first see 3 important reasons teens DON’T self-harm.
1. Teens don’t self-harm for attention or to manipulate
2. They don’t self-harm because it is a fashion or trend.
3. They don’t self-harm because they want to die.
The last possibility especially terrifies parents. However self-harm is not a suicide attempt, as is commonly assumed. The reasoning behind self-harm and suicide attempts are often quite different, though the triggers may be similar. However, teens who self-harm need to be monitored carefully as self-harm can be a long-term predictor of suicide.
So where do teens learn about self-harm? Teens who are already in pain and looking for a solution hear about self-harm from peers who may say self-harm is a way to feel better. Sometimes teens try it out after seeing a TV show, or as a “dare” in a game. However, the idea for self-harm cannot be “put into their head”. Teens who self-harm have an underlying (often undetected) mental health issue. Research by Camilla Haw and colleagues (2001) find that psychological conditions such as a mood disorder (depression or bipolar disorder), a personality disorder (most often borderline personality disorder), eating disorders (such as bulimia) are often associated with self-harm.
Related Reading: When Eating Disorders Wreck A Young Mind
Thinking of self-harm behaviours as manipulation or calls for attention can make them seem like deliberate, conscious blackmail. Self-harm is not always a “call for help” or a manipulative tactic – in reality these are just two of the reasons for self-harm.

Common motives for self-harm seen in my clinical practice include:
• “I wanted the pain to just go away, when I cut it did”
• “I felt so numb, so I used a razor and that’s when I felt something”
• “As soon as I cut I felt immediately better, I got what I deserved” (self-punishment),
• “When I scratch myself I feel I am cleansing myself. (purification)
• “I sleep with a swiss army knife next to me. It gives me reassurance that I can cut anytime the pain gets intense”
• “I wanted to show him/her how much I suffer,” (punish self or others)
The most common underlying reason for self-harm is a way to end emotional pain. Marsha Linehan (1993), the psychologist who originated Dialectical behaviour therapy (DBT), a type of psychotherapy used for reducing self-injury and suicidal behaviour, says “self-harm helps to regulate emotions”. People who engage in self-harm often have trouble calming themselves down when stressed and self-harm reduces an internal state of turmoil and tension. The biological reason behind using self-harm is that any injury prompts the release of endorphins (a brain chemical that acts as natural pain reliever) which leads to a soothing effect. The addictive nature of this feeling can make stopping self-harm difficult.

Signs of self-harm:
• Unusual secrecy, Insisting on keeping doors locked, Spending longer than normal time in the bathroom
• Covering arms and legs, even at home. Avoiding physical activity for fear of exposure of skin in sports clothes
• Razors/knives missing from the home. Finding sharp objects among the child’s belongings.
• Wearing bandages/wrist bands to mask cuts.
• Small, almost invisible cuts (like one would see with a paper cut) appearing on forearm, wrists, legs. Children will make up excuses for these such as “bit by a mosquito and scratched”.
• Appearance of blood stains on clothes or bedsheets, towels
• Sudden mood changes which increases with stressors like exams, disagreements with friends etc. Research finds that Children who find it tough to manage psychological pressures of daily stress often are prone to cutting

How to help your child:
Immediate Action:
• If the injuries are serious immediately consult a doctor, dress fresh wounds or provide first-aid.
• Book an appointment with a therapist
• Ask some questions- How did it happen? Go through the events step-by-step. What did they use to inflict the self-harm? What thoughts were going through their mind? Have they self-harmed before?
• Create a safety plan: Remove dangerous objects (such as pills, blades, knives) from the vicinity. Ensure the teen is not left alone (especially in the bathroom or bedroom) with the door closed. Pick and drop them to school. Discuss with the school to keep a watch on the child and ensure they are not left alone.

What parents should avoid:
• Ignoring the behaviour thinking the more attention they give the worse it gets. Studies show validation reduces self-harm
• Getting angry “I won’t tolerate this nonsense and I will not indulge this behavior”
• Displaying Panic: Don’t overreact to scars or burns. Be matter-of-fact and stay calm.

Long-term:
As you have now learnt, self-harm is a coping mechanism for emotional pain. Therefore, telling a person to stop harming themselves is usually not helpful. What you will, as a parent, need to do is:
1. Recognize the reasons behind the self-harm, so that you understand what triggers the child (a fight with a friend/exam stress etc) and accordingly help them cope.
2. Understand the usual method of self-harm. This can help you create a better safety plan and stay vigilant.
3. Help your child with replacement soothing skills- snapping a rubber band on the wrist, holding a frozen orange, marking the body with a red felt-tipped marker, journaling about self-injury, creating artwork that depicts self-injury, doing physical exercise.
4. Ensure they continue to see their therapist. Self-harm clients often drop out of therapy due to their negative thoughts and mood fluctuations. Reiterate to your child the benefits of seeking professional help.
5. Relapses happen: Dr. Sarah Reynolds, a DBT expert says “Self-harm has an addiction-like quality, relapses are very common”. So, despite your best efforts, if your child does self-harm again, don’t be discouraged. Move on and reinforce positive coping skills repeatedly.
6. Help them put together a soothing kit: Research finds that when the urge to self-harm comes up keeping a soothing kit handy is helpful. In therapy I encourage teens to use a plastic ziplock or any other small bag to place positive and uplifting items. This can include anything they like- pictures of pets, perfumes, a satin cloth, favourite toffee etc. This emergency kit is to be used to help soothe your child when he or she is feeling like self-harming.

To sum up, here’s a quote by Bessel Van Der Kolk, the renowned psychiatrist, known for his work in the field of trauma and attachment “The parent-child connection is the most powerful mental health intervention known to mankind.”

The online version of this article can be found on the Patient’s Engage website.