Young, injured - and tired of life?

Last month, a teacher called me. She no longer knew what to do: She had a pupil who had been regularly scratching her forearm with a razor blade for a good year and a half. For a long time, 15-year-old Pia* had kept the injuries a secret by always wearing long sleeves. But one day, a schoolmate discovered the wounds in the changing room before PE class and turned to the teacher with concern, asking her to help Pia.

The teacher immediately sought a dialogue with the girl, asked to see the injuries and asked why. Pia explained: «By hurting myself, I can deal better with negative feelings and inner tensions.» She didn't want to say any more. The teacher feared that Pia could cut herself so deeply that she would die.

School is usually overwhelmed by self-harm

In many respects, this is a typical situation. According to international surveys, the majority of teachers and school social workers feel insecure when dealing with young people who self-harm.

They usually react with shock, often with compassion and sympathy, but sometimes also with aversion, disgust and a lack of understanding. Many wonder whether the self-harm is an indication of impending suicide. According to their own statements, they often do not know how best to talk to the young people and support them.

Non-suicidal, hurtful behaviour is primarily a way for the young person to reduce tension.

Only in the rarest of cases have members of the aforementioned professional groups received specific training in dealing with such children. Yet almost all of them come into contact with those affected at some point. Self-harming behaviour in adolescence is a very common phenomenon. Worldwide, 18 per cent of under-19s, i.e. almost one in five, report having deliberately harmed themselves physically at least once in the past year.

Far fewer do this on a regular basis. In Germany, around four per cent of young people stated that they had repeatedly injured themselves in the past twelve months (see interview with Marc Schmid on the situation in Switzerland).

They use razor blades or cigarettes, for example, or spray the skin with a deodorant spray at close range, which can lead to cold burns. Some boys also say that they hit their hand against a wall until it bleeds and then feel relief. However, there is no intention of taking one's own life behind any of these behaviours - the technical term is therefore: non-suicidal self-harming behaviour, or NSSV for short.

Suicidal thoughts are common

Nevertheless, the liaison teacher's fear that Pia might commit suicide should not be dismissed lightly: Young people think about it far more than you might think. In a comparative study conducted in 17 European countries in 2012, one in three pupils in Germany stated that they had already thought about suicide at least once.

Around a third of this group, on the other hand, talk about concrete plans to end their own lives. Of these, around two thirds are trying to put this into practice.

Ideally, the helper should not react in shock or panic, but should face the student calmly and compassionately.

In fact, suicide is the second most common cause of death among young people, with four times more boys than girls taking their own lives. But what is the link between self-harming behaviour and suicide? According to studies, the majority of those who self-harm are not suicidal.

It is true that NSSV, if it occurs repeatedly, is a risk factor for suicide attempts. However, experts see it primarily as a coping strategy that enables people to deal better with negative emotions such as stress and inner tension.

Only some of those affected state that it helps them to distract themselves from suicidal thoughts. However, if a student frequently injures themselves more deeply and in unusual places (such as the torso), the risk of suicide appears to be greater.

Over time, the constant injuries increase the pain threshold and thus the risk of life-threatening self-harm.

There are lots of likes for pictures of scratch injuries

In any case, the young people need psychological help. But how can teachers recognise affected pupils? Most children who self-harm, like Pia, do so for the first time around the age of 13 to 14.

From the age of around 17, the numbers start to decline, as a study published in 2015 by researchers led by Paul Plener from Ulm University Hospital showed. Inexplicable scratches and wounds as well as inappropriate clothing - for example long sleeves in summer - can be indicators.

It is advisable not to pay too much attention to the scratching itself, as this may reinforce the behaviour.

Occasionally, teachers may also find sharp objects such as razor blades and knives, or notice that a pupil frequently withdraws during the school day and repeatedly disappears to the toilet, for example. Some young people also make clear texts or drawings.

And it is not uncommon for NSSV to spread like an epidemic among friends: as Paul Plener's team observed in 2016, those affected receive many likes and great sympathy for their pictures of scratch injuries posted on social networks.

Non-suicidal, hurtful behaviour is primarily a way for the young person to reduce tension. Ideally, the helper should not react in shock or panic, but should approach the student calmly and compassionately, in the spirit of respectful curiosity.

What educators can do

Make sure you give the pupil the feeling that you value them as a person, even if you don't approve of the scratching yourself. During the conversation, it helps to adapt to the way the young person expresses themselves by adopting their choice of words. For example, the guidance counsellor could ask Pia: «How does it help you when you hurt yourself?»

She should also make the girl realise that other people - such as her classmates - care about her. Without putting her under pressure, the teacher should emphasise that Pia can expect support from other people: «I may not be the person you want to talk to, but I can help you find someone.»

Some want to punish themselves, others hope that their plight will be recognised and they will be helped.

If the girl refuses to talk to a child and adolescent psychotherapist, the teacher could consult a school psychologist or social worker who is trained in the therapeutic assessment method. This involves special counselling techniques that serve to determine whether there is a need for treatment and also help to motivate those affected to undergo therapy.

It is also advisable not to pay too much attention to the scratching itself, as this may reinforce the behaviour. The teacher should also ask Pia to keep the injuries covered up and not talk about them with classmates.

Self-harm serves to reduce bad feelings

It is not easy to assess the actual risk of suicide. Many young people who self-harm report problems within the family such as parental divorce, trouble with friends and bullying, heartache or difficulties at school.

Psychological stress triggers strong feelings such as sadness, anger and agitation. Like Pia, most young people who self-harm say that it helps them to release these bad feelings.

Some want to punish themselves or hope that others will see their plight and come to their aid. Some also report that it is the pain that enables them to feel themselves or their own limits. Less frequently, they explain that they are looking for a «kick» - which is ultimately often an attempt to escape a feeling of inner emptiness or numbness.

Life-weary pupils often suffer from excessive demands

If one compares the data collected in various studies on NSSV with that of suicidal adolescents, parallels can be recognised. «Life-weary» students feel much more frequently and more strongly confronted with a multitude of stresses that they cannot cope with on their own. Around 90 per cent of those who ultimately commit suicide have already been diagnosed with a mental disorder.

The risk of suicide increases if a young person feels socially isolated because they have no friends or other confidants, or if a serious event such as the death of a loved one has a negative impact on them. A suicide or mental illness in their own family also seems to increase the risk. The guidance counsellor asked Pia during the next interview: «You said that scratching helps you to deal with negative feelings. Do you have any idea what could trigger this?»

The concern that asking a young person about suicidal thoughts is the first thing to give them the idea is unfounded.

It turned out that Pia had been arguing with her mum much more often since her father had moved out a good two years ago. She also said that she didn't have a really good friend and therefore often felt very lonely. The teacher advised Pia to confide in a child and adolescent psychotherapist. They could also give her better advice on how to deal with classmates, teachers and parents.

When is the risk of suicide increased?

According to studies, the risk of suicide is increased when young people report persistent, barely controllable thoughts of harming themselves and also express a strong desire to die.

The same applies if a suicide attempt has already taken place in the past or if the person concerned has already made plans to do so in the past or is currently doing so. The rule here is: if the therapist considers the other person to be at risk of suicide, they should ask directly.

You might think that asking a young person about suicidal thoughts is the first way to get them thinking. However, this fear has been dispelled in controlled studies such as the one conducted by Madelyn Gould and colleagues from Columbia University on more than 2,300 students.

Boys and girls who were questioned in detail about suicidal thoughts were no longer more preoccupied with them two days later. On the contrary: adolescents with depressive symptoms or suicidal ideas - categorised as high-risk individuals - actually tended to feel better afterwards.

Determining the risk of suicide in cases of self-harm

So a psychotherapist could ask Pia: «Does everything get too much for you from time to time, so that you sometimes think it might be better not to be alive?» And if the girl answers in the affirmative, she should follow up: «Have you ever thought about how you would actually do that?»

Or: «Have you already tried to take your own life?» The more openly, calmly and naturally you ask these questions, the more likely it is that the person concerned will answer honestly and open up accordingly. Many young people report that they felt relieved by such questions.

If there is a high risk of suicide, there are usually both acute stressors and a mental disorder that requires treatment.

By taking all these factors into account, it is possible to determine whether the suicide risk is low, medium or high. However, the assessment must be carried out by specialists, such as licensed child and adolescent psychotherapists or child and adolescent psychiatrists.

If there is a high risk of suicide, there are usually both acute stressors and a mental disorder that requires treatment. In this case, therapy may need to take place as an inpatient in a child and adolescent psychiatric clinic.

If, on the other hand, the young person credibly affirms that they do not want to harm themselves, they can be treated as an outpatient, for example in a paediatric psychotherapy or psychiatry practice.

Half of those affected are happy to receive help

The guidance counsellor managed to convince Pia that she needed the support of other people, especially her parents. With the girl's consent, she therefore talks to her mother and father.

In it, she explains that Pia still feels very burdened by their separation, especially when they take their disagreements out on their daughter. Together with her mother, Pia finally decides to meet with a child and adolescent psychotherapist on a trial basis. She does not see any acute risk of suicide.

Pia likes the therapist, so she agrees to see her once a week. Pia's willingness to undergo therapy is no exceptional stroke of luck. According to surveys, around half of those who self-harm actually want to stop the behaviour - so offers of help should fall on fertile ground with them.

In therapy, the individual triggers are identified. If a pupil reports bullying, for example, this problem should be addressed together with the teachers. However, due to the «risk of infection», the topic of NSSV itself should never be discussed in front of the class. Interventions at class level should only deal with more general aspects, such as: «How do I deal with pressure and stress?»

Frequent relapses with self-harm

In the next step, the therapist can work with the young person to consider which so-called skills he or she could use instead of self-harming behaviour. These are skills that are effective in the short term without causing long-term harm.

These include mindfulness exercises, relaxation techniques such as autogenic training, distraction - listening to music, going jogging, playing Playstation - and sometimes even something like biting into a chilli pepper when an intense stimulus is needed.

Because everyone responds differently to the various skills, it is often necessary to try out a number of variants before the right one is found. Especially in difficult times, relapses occur more frequently at first, which should not demotivate helpers or those affected.

It is much more important to scrutinise the triggers together and consider how the young person could react differently and what alternative coping strategy they could try out next time.

Pia, for example, can't cope with the relaxation exercises, she simply can't let go of her negative thoughts. As she is sporty, the therapist advises her to put on her jogging shoes at home after a stressful argument and «run the anger off her chest». Studies have long since proven that this recommendation also makes sense from a medical point of view: After just a short time, physical activity triggers processes in the body that lift the mood.

* Name changed

This article first appeared in the magazine «Gehirn + Geist».