Self-Harm: When Emotional Pain Becomes Physical Pain

Non-suicidal self-injury (Non-Suicidal Self-Injury - NSSI) is defined as intentional injury to body tissue, without an intention to die as a result of the act. It may occur in adolescence as well as adulthood, among people experiencing various emotional difficulties, and sometimes without a defined psychiatric diagnosis.

It is important to distinguish non-suicidal self-injury from a suicide attempt, but also to understand that the distinction is not always straightforward. Both phenomena may occur in the same person, and a history of self-harm is associated with an increased risk of subsequent suicidal behavior. Therefore, it should not be assumed that the absence of reported suicidal intent means an absence of risk.

When a person experiences severe emotional distress, they may look for a quick way to change their inner experience. For some people, self-harm creates a temporary change in their emotional state: reduced tension, a sense of control or a shift from a vague emotional feeling to a clearly defined physical sensation. For others, it may instead briefly interrupt a sense of emptiness or emotional disconnection. Relief, when it occurs, does not mean that the behavior is helpful in the long term. It may increase the likelihood that the person will repeat it during further distress. A pattern may thus develop in which a dangerous action becomes a familiar and readily available means of coping.

One common mistake is to assume that all self-harm has the same meaning. In practice, the behavior may serve different functions:

• Reducing emotional tension or anxiety.
• Coping with a sense of emptiness or disconnection.
• Expressing self-directed anger, guilt or self-punishment.
• An attempt to regain a sense of control in a state of helplessness.
• Communicating distress that is difficult to express in words.

Sometimes several motives coexist, and they may change from one event to another. Understanding the behavior therefore requires individual exploration rather than reliance on general explanations.

People who harm themselves may experience profound shame surrounding the behavior. Some hide the injuries out of fear of others’ reactions, punishment, rejection or losing control over their personal information. Sometimes a cycle develops in which distress leads to self-harm, followed by guilt, shame and fear of disclosure. These emotions may increase isolation and reduce the possibility of receiving support.

A critical response from those around them may deepen concealment, even when it stems from genuine concern.

Adolescence is characterized by significant emotional, physical and social changes. At this stage, personal identity, a sense of belonging and the ability to cope independently with stressful situations are taking shape. For some adolescents, social difficulties, experiences of rejection, self-criticism or family distress may be associated with the onset of self-harm. However, it should not be inferred that the behavior necessarily stems from family difficulties, trauma or social influence. All contributing factors need to be examined. When an adolescent discloses self-harm, it is important that the adults around them take it seriously, even if the injury appears minor.

The initial response may affect the person’s willingness to continue sharing and seek help. Rather than responding with blame or demanding a promise that it will not happen again, it is important to try to understand what preceded the behavior and what the person experienced at that moment. You can gently ask:

"What were you feeling before it happened?"

"What changed in how you felt afterward?"

"Were there moments when you felt you might harm yourself but did not do so?"

It is also important to ask directly about suicidal thoughts, an intention to die and immediate danger. Direct questions about suicide do not, in themselves, increase suicide risk.

When a minor is involved, responsible adults and professionals should be included according to the level of risk, while preserving their dignity and privacy as much as possible.

Treatment for self-harm is not limited to demanding that the behavior stop. It includes risk assessment, exploring the factors that maintain the harm, identifying triggering situations and developing safer ways of coping.

DBT uses behavior chain analysis to examine what happened before the harm, which thoughts and emotions appeared and what the consequences of the behavior were. Therapeutic work may also include developing the ability to ask for help, addressing self-criticism, building a safety plan and strengthening sources of support. Treatment is adapted to age, level of risk and individual needs. In some cases, a psychiatric assessment or attention to co-occurring mental health conditions is also required.

Self-harm is a behavior that should be taken seriously, but it does not define the person experiencing it. Behind it may lie emotions that are difficult to express, experiences that have not been processed or coping patterns that developed over time. Understanding the function of the behavior does not justify it, but makes it possible to build a more precise therapeutic response.

The aim is not only to stop the harm, but to help the person develop safe ways to cope with distress, express their needs and experience greater control and security in their life.

Self-harm is a sign of distress that requires professional attention, even when the person states that they do not intend to end their life. Urgent attention is needed when there are suicidal thoughts, an intention or plan to cause serious harm, an escalation in the frequency of injuries, a significant injury or concern that the person cannot keep themselves safe.

In a situation of immediate danger, do not leave the person alone. Remove dangerous means as far as this can be done safely, contact local emergency services or go to the nearest emergency department. Even in the absence of immediate danger, it is important to seek a professional assessment promptly from a qualified mental health professional. A promise from the person that they will not harm themselves again is not enough.

It is important to remember: seeking help is not an expression of weakness, but a significant step in protecting life and creating the possibility of change.