How to Help a Teenager Who Self-Injures
Conduct a comprehensive therapeutic assessment immediately after discovery, establish an empathic relationship, involve the family appropriately, and arrange for Dialectical Behavior Therapy for Adolescents (DBT-A) if available, or modified CBT with family involvement if DBT-A is not accessible. 1
Immediate Assessment and Safety
After discovering self-injury, perform a therapeutic assessment that goes beyond simple risk prediction. This assessment should:
- Develop a formulation identifying what specifically needs addressing: concurrent depression, eating disorders, problematic internet/social media use, and other contributing factors 1
- Create a safety plan rather than focusing solely on risk prediction—safety planning shows promise in reducing future self-harm 1
- Remove all firearms from the home and lock up all medications (prescription and over-the-counter), as adolescents can access even locked guns 2
The lack of current suicidal thoughts after a self-injury episode can be misleading if the underlying factors haven't changed. Always give the benefit of the doubt—even adolescents who joke about self-harm may be asking for help the only way they know how 2.
Establish an Empathic Therapeutic Relationship
The quality of your relationship with the teenager is critical. Negative clinical experiences can perpetuate cycles of self-harm 1. Use approaches like Collaborative Assessment and Management of Suicidality or Therapeutic Assessment, which improve engagement between clinicians and young people 1.
Stigma is the primary barrier preventing teenagers from disclosing self-injury 3, so creating a non-judgmental, youth-centered environment is essential for ongoing communication.
Treatment Recommendations
First-Line: DBT-A (When Available)
DBT-A shows the most promise for reducing both absolute repetition and frequency of self-harm in young people 1. However, it's a prolonged, intensive therapy requiring highly experienced clinicians, making it unrealistic for most teenagers 1.
Alternative: Modified CBT with Family Involvement
When DBT-A isn't available:
- Use CBT adapted for adolescents with modified language and family involvement 1
- Include specific self-harm and suicide-related content when treating concurrent depression, as self-harm ideation may persist even when depression improves 1
- Involve family members to reduce non-adherence and improve outcomes, but tailor the extent carefully based on the teenager's views 1
Brief Interventions for Limited Resources
If time or resources are constrained:
- Safety planning interventions can be effective even in single encounters 1
- Regular follow-up contact (including telephone contact) may help in lower-resource settings 1
- Care coordination as a brief intervention shows promise 1
Medication Considerations
Do not use pharmacotherapy solely for preventing self-harm in teenagers 1. No published trials support this approach, and even in adults, tested medications show no benefit for self-harm endpoints 1.
However, vigorously treat underlying psychiatric disorders (like depression) with appropriate medications when indicated, as this decreases short-term and long-term suicide risk 2. When prescribing antidepressants, monitor carefully with frequent appointments and educate families about warning signs: new/increased thoughts of dying, self-destructive behavior, increased anxiety/panic, agitation, impulsivity, or restlessness 2.
Risk Stratification and Referral
For moderate to high-risk teenagers, arrange immediate mental health evaluation during your visit 2:
- High risk indicators: Previous attempts, high intent, serious depression/psychiatric illness, substance use, low impulse control, unsupportive family
- High-risk action: Psychiatric hospitalization provides a safe environment for complete evaluation and treatment initiation 2
For lower-risk teenagers: Still provide close follow-up and timely mental health referral if any significant dysfunction or distress exists 2.
Ongoing Management
- Maintain contact even after referrals—collaborative care results in greater reduction of depressive symptoms 2
- Screen routinely for mood disorders, substance use, suicidal thoughts, bullying, and sexual orientation during all adolescent visits 2
- Assess internet and social media use, as digital exposure to self-harm content has significant predictive value for self-injurious behaviors 1, 4
Common Pitfalls to Avoid
"No-harm contracts" are not proven effective in preventing suicidal behavior, though refusal to agree is an ominous sign 2. Focus instead on concrete safety planning with specific steps for moments of distress 2.
Don't assume low lethality means low risk—a teenager taking 8 ibuprofen tablets may have believed it was lethal and could attempt something more dangerous next time 2.