Adolescent Self-Harm: The First Five Minutes Will Make All the Difference

Amber, a 16-year-old girl with Major Depressive Disorder and a history of two psychiatric hospitalizations for self-harm attempts (cutting), has been alone in her bedroom all day with the blinds shut. Her mother, Jennifer, is worried so she goes into Amber’s room and notices she’s curled up on her bed wearing a long sleeved sweatshirt despite the warm weather. Jennifer knows what this probably means—Amber has cut again. Jennifer asks Amber if she is okay but Amber yells at her mom and tells her to get out of her room.

What Jennifer says and does with Amber in the next 5 minutes is likely going to determine the outcome of this event: it’s either going to be a call to 911, a trip to the ER, and another stay in the hospital. . . . 

What Jennifer says and does with Amber in the next 5 minutes is likely going to determine the outcome of this event: it’s either going to be a call to 911, a trip to the ER, and another stay in the hospital. . . . or, something altogether different and far more helpful for her daughter.

In Intensive In-Home Family Treatment (IIFT), we view parents as the single best resource for children and adolescents with serious mental health conditions, consistent with a substantial body of research which supports that family-based treatment is a far more effective intervention than directing therapies exclusively or even primarily toward the child alone. 

This example illustrates why. If this family was emotionally disconnected, reactive under stress, not communicating well, or unskilled at collaboratively navigating and supporting Amber’s mental health illness, this event would almost certainly result in another hospitalization. Assuming that Amber’s mental health condition is not going to change overnight (it won’t), her family—the people who love and care about her more than anyone else in the world—is best positioned to help her at this moment in which she is hurting and needing their love and support and other moments like this well into the future. 

Our goal in IIFT with a family in this situation would be to teach them how to collaboratively navigate Amber’s self-harm, which might include the following treatment interventions:

·        Assess Amber’s motivation to avoid hospitalization; if her motivation is low, implement strategies to increase her motivation.   

·        Establish with Amber and her family a treatment goal of helping her stay out of the hospital (“Our goal as a family is to do what we can together so you don’t have to go to the hospital because we love you and always prefer you here with us.”)

·        Teach Amber’s parents that self-harm and suicide aren’t the same thing; someone can harm themselves but still be safe enough not to go to the ER.

·        If the injury does require medical attention, teach the family how to collaborate with the ER staff to develop a safety plan to immediately return Amber back home if possible.

·        Work with Amber so she can reach out to her family for comfort and support rather than shutting down and going inward; remove barriers that prevent Amber from reaching out (“My parents don’t know what to say to me when I get like that.”) 

·        Teach her mom how to gently offer support in those first 5 minutes (“I’m guessing right now you’re really hurting and I’m wondering if you’re in a space to talk to me about what you’re feeling?” and “What are wanting or needing from me right now that would be most helpful?”) rather than getting frustrated, annoyed, or critical (“This for attention, isn’t it, Amber?”)

·        Develop resources within the family that have been identified in family therapy sessions that are likely to be helpful: “How about we go for a walk, watch a movie together, play a game together”, etc.

This type of challenging event or events like this are common with IIFT families. An important component of the treatment model is the 24/7 availability of the clinical team to the family for coaching and support, as well as our ability through the cameras installed in the home to witness the event as it’s unfolding. Should something like this occur, the parents would immediately reach out the team and we would consider a number of variables simultaneously that would guide our coaching of family, such as:

·        How long has the team been working with the family? We are much more directive with newer families (“Here’s what we think you should do”) than we are with families who are farther along in treatment (“Ok how would you like to handle this?”)

·        Are the parents reasonably able to stay calm in a situation like this or should our initial focus be on de-escalation and soothing?

·        What is Amber’s history of self-harm? Is it predominantly nonlethal or has she sometimes hurt herself more seriously? (The latter would require a greater focus on safety.)

·        What is Amber’s knowledge of and willingness to use emotion regulation and/or distress tolerance skills?

·        If this is a two-parent household, which parent is historically better able to connect and soothe Amber in moments like this?

·        Is Amber reasonably connected to her individual therapist on our team? If so, the therapist would immediately reach out to Amber to assess safety and create a plan to get her back on track.

·        How motivated is Amber to avoid hospitalization? The more motivated she is, the more we would help advocate on her behalf with the ER staff to safely return her back home rather than send her to a hospital.

In IIFT, we see Amber’s self-harm as a family problem to solve, not an Amber problem to solve. All of our clinical interventions are therefore focused on optimizing the family’s response to an event such as this to ensure a quick recovery and get the family back on track as quickly as possible.