Jul 9, 2021

Interviewer: Dr. Thomas Conover is a psychiatrist. He's board-certified in both child and adolescent psychiatry in general pediatrics. And you've noticed some signs that your child is engaging in self-harm which can be a scary and very confusing thing to deal with as a parent. So what do you do? That's what we're going to find out today.

I'm going to give you some information that'll help you identify if your child is actually engaging in self-harm, how you should respond, and also some resources for help and for treatment as well. So let's start with that very first question. As a general rule, what is self-harm? How do you define that as a psychiatrist?

Dr. Conover: Self-harm is any deliberate attempt or act to injure oneself. So the term is pretty straightforward, but self-harm includes, from a psychiatrist's standpoint, both non-suicidal self-injury, which is any self-harm that's inflicted without any intent to die and also suicide attempts. So suicide attempts are a form of self-harm and the difference between the two as we define them is really whether the person who's inflicting injury on themselves means to die by doing it.

Interviewer: So when I hear self-harm, I tend to think of cutting. Is that the only type of self-harm or there are some other types as well?

Dr. Conover: Making cuts there's scratches on oneself are by far the most common type of self-harm. We also sometimes see teens do other forms such as burning themselves deliberately, or hitting themselves, striking themselves with a fist or headbanging. Those are other forms that are fairly frequently seen. There are numerous other less common acts, but cutting or scratching on oneself is definitely the one that we see most frequently in emergency rooms or psychiatric specialty care.

Interviewer: What leads to that type of behavior?

Dr. Conover: We don't know the exact reasons why any individual might engage in self-harm. You know, for each individual teen, it may be different. Some of the reasons may be as a distraction or relief from some other thought or emotion. Sometimes it may be kind of the cliché or proverbial cry for help, you know, trying to express some emotion or demonstrate distress that are too difficult for the teen to articulate in words. Those are two of the most common reasons that we see teens engage in self-harm behavior.

Interviewer: Have you experienced with any of your patients the teen actually talking about self-harm before engaging in it? You said that self-harm is in itself a form of communication and could be an indication to a parent that I want to have a conversation about something with you, I just don't know how to do it, so I'm doing it this way. But could it happen in terms of words before behaviors?

Dr. Conover: It certainly can. Many times it may be expressed to someone other than the parent, to a friend or acquaintance, somebody that the teen is communicating with over texts or social media. And, in fact, that's often a way that parents discover that their teen is either thinking about or engaging in that behavior. One warning sign and one piece of good advice for any parent of a teen is to monitor the teen's social media use and texts with some frequency because sometimes that's who they may try to talk about that too. Now, if a teen is actually coming to a parent or other trusted adult and expressing thoughts that he or she may harm themself, I would say that that's . . . while that's a concerning situation, it's certainly a situation where at least the teen feels trusting enough and supported enough to bring that up verbally before doing it or even after doing it. And in some sense, in that situation, the teen and their caregiver are a step ahead of where they might be if the self-harm thoughts or behavior are completely concealed.

Interviewer: Is it generally pretty easy in your experience for parents to recognize if their teen is engaging in self-harm?

Dr. Conover: I don't think it is, but I think the barriers to recognizing it are complex. One of the main barriers being that no parent wants to think that their child is experiencing the kind of distress that would lead them to deliberately harm themselves or to attempt suicide. And so a certain degree of conscious or unconscious denial is a huge barrier to recognition. So I think to anybody who is listening to a podcast like this, to anybody who's wanting to know more about teens' mental health, I think having awareness is a way to bring that barrier down. You know, as much as a parent doesn't want to think that their child might be experiencing that distress, some awareness and a level of openness to the possibility brings that barrier down.

Supervision and support is another thing that brings that barrier down. When a parent pays attention to their teenage child, when a parent knows what he or she is doing, who they're hanging out with, who they're communicating with, when a parent enquires actively and openly with their teen in a way that lets the teen know that they're caring and concerned, those are also things that bring down the barrier and make it more likely that the teen might actually talk to the parent about such behaviors.

Interviewer: I would imagine if somebody is listening to our conversation right now and they found it via internet search, they probably should trust their instincts. Would you say that's a safe thing to say?

Dr. Conover: If the parent has a suspicion or a concern, then I think that they should not dismiss that. The most direct first step would really be to initiate a conversation. Initiating a conversation about self-harm needn't be accusatory. In fact, it shouldn't be because that's a sure-fire way to have a teen shut down in conversation for a parent to approach them and say, "Are you cutting yourself? You should never do that." Right?

Interviewer: Yeah.

Dr. Conover: To imply a judgment or to seem like you're interrogating. You know, a better opening line might move from the general to the specific in a manner like, "You know, some teens, when they're feeling upset or distressed, might even think about hurting themselves or even hurt themselves on purpose. Have you ever thought of doing something like that?" You know, you can hear the difference when you're talking about saying, "Hey, this is not something that you alone might have thought of or done. This is not something that I'm expressing any judgment about. I'm just saying it's something that people might do, And I'm wondering if that's something that you've ever thought about."

Asking about thoughts is a little bit of a softer entry too, right? Because the team doesn't necessarily have to confess, "Oh, yeah, I did cut myself once." Maybe they're not ready to say that, but they might be ready to say, "Well, yeah, you know, I've known some people who have done that or I've heard that people do that or I've even thought about it myself." And then the conversation can proceed from there. Like I said, it doesn't have to be accusatory or judgmental and it shouldn't be, but is it going to be a difficult and crucial conversation? Absolutely. There's no way to make that kind of an inquiry easy.

Interviewer: You bring that up with your teen, you ask them if they've ever thought about it, but there are obvious signs that something, you know, is going on. Is that the point that you say, "Well, I couldn't help but notice that on your arm there are scratches or on your legs, there's bruises?"

Dr. Conover: Yeah. I think that being gentle in inquiry is important, but we don't have to take it to the point of absurdity, right. You know, if what the parent is concerned about is something concrete like, "I found a text where you said to your friend that you were thinking of hurting yourself, or when we were at the beach last Saturday and you were wearing your shorts, I noticed that you had some cuts on your leg." I think that it's fair for a parent to start with the concrete thing that the parent observed. That's reasonable. Again, not being accusatory or judgmental, right? Not, "What on earth are those that I saw on your leg during our trip to the beach?"

Interviewer: Yeah. "What are you doing to yourself?"

Dr. Conover: "Who does something like that?" Exactly, right? But just saying, "I noticed this, or I found this, or when I was looking at your texts from last week, I saw something that concerned me." I think that mustering some calm and then actually inquiring with the child is perfectly appropriate. And I think that does point to signs that a parent may look for. You know, it is my experience that most often it isn't the case that the teen will come to a parent and simply say, "I'm thinking about this, or I'm engaged in this behavior." It would be nice if they did. It's a good sign about the parent and child's communication if a child can openly state that.

However, more often, I see parents discovering signs that this might be happening. Signs that one might look for include finding items that someone might use to harm themselves in a place where you wouldn't expect to find that thing, like a kitchen knife in a bedroom, or old-fashioned razorblades, you know, that you might use to peel paint or do things like that hidden somewhere in a child's room, pieces of glass or metal. Certainly, if any of those items look like they've been used because they have, you know, blood or something that looks like that on them.

So finding items that a youth might use to harm themselves, that's one very common sign that parents might first come upon. A very common way is through monitoring social media or texts. I think it's very important to note that monitoring social media and texts should be given and what I advise parents to do before they let kids use those technologies is to set down a very clear contract and expectation that they will be monitoring their activity because that's necessary and it also avoids the conflict that would arise if a parent was monitoring those things without having set that expectation.

Interviewer: When a parent recognizes these signs and they have addressed them with their teen and they've started out the way that you've recommended, being very non-accusatory, talking about the physical things that you're seeing as opposed to passing judgment and you get that conversation going, you had mentioned that sometimes self-harm is a way of communicating that there's something else going on. I love keeping that in mind. I think as you're having this conversation is ultimately the point then to get to what the actual problem is that's causing the symptom of self-harm or is that the time you would want to involve a professional, or where would you go from that point?

Dr. Conover: An older view in mental health was that deliberate self-harm or suicidal thoughts or acts were always secondary to some other problem or a symptom of another disorder, and that you would need to treat the disorder in order to treat the self-harm behavior or the suicidality. To an extent, that is true, but a more current and up-to-date view is that while self-harm and suicidal acts can be associated with another problem like depression, or trauma, or abuse being two of the most common, they do constitute a problem in and of themselves. I don't think that a parent is best served to then become the behavioral health provider or a detective, right? You know, to say, "I'm going to get to the bottom of this. I'm going to get to the bottom of this and find out what's ailing you and what's causing this problem you're having." That's not something a parent wants to pursue on their own.

I think the first step of asking your child, "Hey, what's going on? I noticed this, or I noticed that. I'm concerned about you." That is definitely the parent's job. The parent's next job is then to help their teen by seeking some additional help and support. Self-harm thoughts, self-harm behavior, those are always a concern and virtually always merit some further support, whether that be through seeking some crisis services, or counseling, seeking some outpatient therapy, getting some additional support from a medical provider like a primary care doctor or other practitioner who maybe already knows the family and the child as a first step are what I would advise if that first conversation happens, really, no matter how that conversation goes, because a parent can do the right thing and ask the question, but the teen may still respond with denial. And I don't think that I would be giving good advice if I said, "Okay, ask these questions and ask them in a non-judgmental way." And you think they might be hurting themselves and you ask, and they say, "No, mom, I'm not doing that." You can't really close the book on the conversation with just that negative reply if you've seen signs or have a strong suspicion.

Interviewer: So the purpose of this conversation is to really have a mutual acknowledgement that this thing is happening. That's the place that a parent wants to get to with their child, expressing concern them so then that they can have a conversation about what we're going to do about it, which is ultimately going to lead to going to a professional to assist at that point.

Dr. Conover: That would be the way that I would advise that things would go. Not all teens who deliberately harm themselves make suicide attempts, but there is a strong correlation between the two. So engaging in self-harm without an intent to die is a strong risk factor and has a strong correlation with eventually making a suicide attempt. And so taking it very seriously when there are signs of such behavior or when there is an admission or confirmation of such behavior is really important because ultimately, you know, we're not concerned about the long-term health implications of having a few cuts or scars on your arm or your leg. What we're concerned about is bigger issues of health and wellbeing and ultimately safety and preventing any very serious injury or death.

Interviewer: Do you have resources that could go beyond this conversation that could help a parent that finds themselves in the situation where they have to have this conversation?

Dr. Conover: Resources that a parent might reach out to would include primary care providers. I think that primary care providers are a great first resource for families for a number of reasons. Primary care providers such as a pediatrician or a family practitioner generally have an ongoing relationship with the teen and the family. And so any discussion or decisions that are made will have a lot of context, and that there's a higher likelihood that the teen and family will feel trusting and agreeable to any advice or interventions that a primary care provider can give. Also, it's generally, unfortunately, we don't have enough mental health providers as far as specialty mental health providers like psychiatric providers and therapists, and so it may be easier and more accessible to start with primary care. At any point where self-harm thoughts or behavior, including suicidal thoughts or suicide attempts are a concern, a parent can always access the crisis services that are available.

Here locally in Salt Lake City and in the entire state of Utah, the Utah crisis line is one such resource and the Huntsman Mental Health Institute crisis line, which are actually staffed by the same, very skilled, highly-trained crisis-intervening staff are both numbers that parents can call. And a parent might question, "Oh, is this big enough of a problem for me to call the crisis line?" As a practitioner, I would always give the advice, don't second guess yourself on whether you think this is a crisis. You are not going to call the Utah crisis line with a question about your child's self-harm or potential suicidal behavior and be told, "Hey, this isn't a problem. Why did you call us?"

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