Supporting Someone Who Self-Harms: A Compassionate Guide for Family and Friends

What Is Self-Harm and Why Do People Do It?

Self-harm, also known as non-suicidal self-injury (NSSI), involves deliberately hurting oneself as a way to cope with emotional pain, trauma, or overwhelming feelings. Common forms include cutting, burning, hitting, or scratching. It affects approximately 17% of adolescents and 5% of adults globally, and is more common in females. Self-harm is not typically a suicide attempt, but it is a sign that the person needs help developing healthier coping strategies.

Understanding why someone engages in self-harm is crucial for providing effective support. Self-harm is rarely about seeking attention or manipulation - these are harmful misconceptions that prevent people from getting the help they need. Instead, self-harm usually serves one or more of the following functions for the person experiencing it.

For many people, self-harm provides a release from intense emotional pain. When internal feelings become unbearable, physical pain can feel like a temporary escape or a way to externalize what they're experiencing inside. The act of self-harming can trigger the release of endorphins, which temporarily relieves emotional distress and creates a sense of calm or relief.

Some individuals use self-harm as a way to feel something when they're emotionally numb. Depression, trauma, and dissociation can cause feelings of emptiness or disconnection from reality. Physical pain can serve as a way to feel alive or present in one's body again. Others may use self-harm as a form of self-punishment, particularly those struggling with low self-esteem, shame, or guilt related to past experiences or perceived failures.

Common Forms of Self-Harm

Self-harm can take many forms, and recognizing these is important for identifying when someone may need support. The most recognized form is cutting, which involves using sharp objects to create cuts or scratches on the skin, most commonly on arms, legs, or stomach. However, self-harm includes many other behaviors.

• Cutting: Using sharp objects to make cuts or scratches on the skin
• Burning: Using heat sources like lighters, matches, or heated objects
• Hitting or punching: Striking oneself or objects to cause bruising
• Scratching or picking: Scratching skin until it bleeds, or picking at wounds to prevent healing
• Hair pulling: Known as trichotillomania when compulsive
• Ingesting harmful substances: Swallowing objects or substances

Risk Factors for Self-Harm

While anyone can engage in self-harm regardless of background, certain factors increase the risk. Understanding these can help you recognize vulnerability in your loved one and address underlying issues. Mental health conditions such as depression, anxiety, borderline personality disorder, eating disorders, and post-traumatic stress disorder (PTSD) are strongly associated with self-harm.

A history of trauma, including childhood abuse, neglect, sexual assault, or bullying, significantly increases the risk. Difficulty expressing or regulating emotions, known as emotional dysregulation, is another key factor. Having friends or peers who self-harm can also increase risk through social learning, and the availability of information about self-harm methods online has raised concerns about potential contagion effects.

What Are the Warning Signs That Someone Is Self-Harming?

Warning signs of self-harm include unexplained cuts, burns, or bruises; wearing concealing clothing even in warm weather; spending excessive time alone; keeping sharp objects or first-aid supplies hidden; blood stains on clothing or bedding; difficulty handling emotions; talking about feeling worthless; and social withdrawal. However, not everyone displays obvious signs, and some hide their self-harm very effectively.

Recognizing the signs of self-harm can be challenging, as many people go to great lengths to conceal their injuries. Being aware of potential warning signs can help you identify when someone you care about may be struggling and offer support earlier in their journey. Physical signs are often the most obvious indicators, though they may be hidden.

Unexplained or frequent injuries such as cuts, burns, bruises, or scratches that they can't explain or have implausible explanations for should raise concern. Pay attention if the person consistently wears long sleeves, pants, or wristbands, even in hot weather, as this may be an attempt to cover injuries. Scars, particularly in regular patterns, may indicate previous self-harm, and you might notice fresh wounds in various stages of healing.

Behavioral and Emotional Signs

Beyond physical indicators, behavioral and emotional changes can signal that someone is struggling with self-harm. Social withdrawal is common - the person may isolate themselves from friends and family or spend extended periods locked in their room or bathroom. They may become secretive about their activities or defensive when asked about injuries.

Emotional instability is another key indicator. This includes frequent mood swings, emotional outbursts, or expressing feelings of hopelessness, worthlessness, or self-hatred. The person may talk about feeling empty, numb, or out of control, or express that they don't deserve happiness or good things in life. Changes in eating or sleeping patterns, declining academic or work performance, and loss of interest in previously enjoyed activities can all accompany self-harm behaviors.

How Do I Talk to Someone Who Self-Harms?

Approach the conversation with compassion and without judgment. Choose a private, calm moment and use open-ended questions like "I've noticed you seem to be struggling - would you like to talk?" Listen without interrupting or trying to fix things immediately. Avoid expressing shock, anger, or disgust. Let them know you care and want to understand. Don't make promises you can't keep, and avoid ultimatums about stopping.

Having a conversation about self-harm can feel daunting, but your willingness to engage with this difficult topic can be incredibly meaningful to someone who is struggling. The way you approach this conversation can significantly impact whether they feel safe enough to open up and seek help. The most important thing is to come from a place of genuine care and openness.

Before starting the conversation, take time to prepare yourself emotionally. Your loved one may share difficult information, and your reaction will matter. If you feel you might react with shock, anger, or panic, it may help to process your own feelings first - perhaps by talking to a counselor yourself or doing research to better understand self-harm. The goal is to be able to receive whatever they share with relative calm.

Starting the Conversation

Choose a time and place where you can talk privately without interruptions or time pressure. Avoid confronting them immediately after you've discovered evidence of self-harm, as emotions will be heightened. A quiet, neutral setting where they feel safe is ideal. Start with open-ended observations rather than accusations or assumptions.

You might say something like: "I've noticed you seem to be going through a difficult time lately. I care about you and I'm here if you want to talk about anything." Or, "I've been worried about you. You can share anything with me, and I won't judge you." If you've seen evidence of self-harm, you might gently say: "I noticed some marks on your arm. I'm not angry or upset - I'm concerned because I love you. Can we talk about what's going on?"

Listening and Responding

Once they start talking, your primary role is to listen. Resist the urge to immediately problem-solve, offer advice, or share your own experiences. Active listening means giving them your full attention, maintaining eye contact, and using nonverbal cues to show you're engaged. Allow silences - these can give them space to gather their thoughts and share more.

Reflect back what they're saying to show you understand: "It sounds like you've been feeling really overwhelmed lately." Validate their emotions: "That sounds incredibly painful. It makes sense that you've been struggling." Ask follow-up questions that show genuine interest: "What does it feel like when you get the urge to hurt yourself?" or "What usually triggers those feelings?"

Avoid minimizing their experience ("It could be worse"), comparing them to others ("Other people have bigger problems"), or offering quick fixes ("Have you tried meditation?"). These well-meaning responses can make them feel misunderstood and less likely to open up again.

How Can I Help Someone Who Self-Harms?

To help someone who self-harms: stay calm and be present; listen without judgment; express unconditional care; encourage professional help without forcing it; learn about self-harm to better understand; help them identify triggers and alternative coping strategies; create a safety plan together with professionals; and maintain the relationship even when it's difficult. Remember that you cannot "fix" them - your role is to support their healing journey.

Supporting someone who self-harms requires patience, consistency, and a delicate balance between being helpful and respecting their autonomy. Your role is not to cure them or force them to change - recovery must come from within. However, your support can create the conditions that make recovery more possible. The foundation of helping is maintaining a consistent, caring presence in their life.

Continue to include them in activities and check in regularly, even if they don't always respond positively. Isolation often worsens self-harm behaviors, so your ongoing connection matters. Be reliable - follow through on what you say you'll do. Trust is crucial for someone who may have experienced betrayal or invalidation from others. At the same time, avoid becoming their sole source of support, as this can create unhealthy dependency and burnout for you.

Encouraging Professional Help

While your support is valuable, professional treatment is typically necessary for recovery from self-harm. Gently encourage them to seek help from a mental health professional, such as a psychologist, psychiatrist, or licensed counselor. Frame this as a positive step rather than a sign of failure or weakness. You might say: "Talking to someone who specializes in this could give you more tools to cope. Would you be open to trying it?"

Offer practical support to remove barriers to treatment. This might include helping them research therapists who specialize in self-harm, offering to make the appointment, accompanying them to the first session, or helping with transportation. If they're resistant to therapy, explore what's holding them back. Is it fear of being judged? Concerns about confidentiality? Financial worries? Address these concerns as best you can.

If they're a minor, you may need to involve parents or guardians, which can feel like a betrayal of trust. Be honest with them about why you need to tell an adult, and emphasize that it's because you care about their safety. If possible, include them in the conversation with the adult so they feel less out of control.

Practical Support Strategies

Beyond encouraging professional help, there are practical ways you can support someone who self-harms in their daily life. Help them identify triggers - the situations, emotions, or thoughts that typically precede the urge to self-harm. Once triggers are identified, you can work together on strategies to avoid or cope with them.

Learn about alternative coping strategies they can use when urges arise, and offer to practice these with them. Alternatives might include holding ice cubes for intense sensation without injury, doing physical exercise to release tension, calling you or another support person, creative expression through art or writing, deep breathing or grounding exercises, or using a stress ball or other physical outlet.

How Do I Create a Safety Plan Together?

A safety plan is a written document created with the person and their mental health provider that outlines warning signs, coping strategies, support contacts, and steps to take during a crisis. It should include: personal warning signs that a crisis is developing; internal coping strategies they can use alone; people and places that provide distraction; friends or family who can help; professionals and crisis services to contact; and steps to make the environment safer.

A safety plan is a crucial tool for managing self-harm and preventing crises. Unlike a contract that says "I won't self-harm," which can create guilt and secrecy, a safety plan acknowledges that urges will occur and provides a roadmap for navigating them. The plan should be developed collaboratively with the person who self-harms and, ideally, their mental health professional.

The safety plan works as a step-by-step guide that the person can follow when they're feeling the urge to self-harm. Each step is attempted in order, moving to the next if the previous step doesn't sufficiently reduce the urge. The plan should be written down and kept somewhere accessible - on their phone, on paper in their wallet, or posted where they'll see it during difficult moments.

Components of an Effective Safety Plan

The first component involves identifying personal warning signs - the specific thoughts, emotions, physical sensations, or situations that indicate a crisis is developing. These might include thoughts like "I can't cope," feelings of numbness or intense anxiety, physical tension, or being in certain triggering environments. Recognizing these early warning signs can allow for intervention before urges become overwhelming.

Next, the plan lists internal coping strategies - things they can do on their own to manage urges without involving others. These might include physical activities like running or cold showers, distraction techniques like watching a specific show, or self-soothing activities like listening to calming music. Then comes social coping - people and places that can provide positive distraction without requiring disclosure about what's happening.

The plan also includes specific people they can call for support when coping strategies aren't enough. This should include contact information for friends, family members, crisis lines, and their therapist. Finally, the plan outlines steps for making their environment safer during high-risk times, such as having someone hold onto certain items or staying in a less triggering location.

When Should I Seek Emergency Help?

Seek emergency help immediately if the person: has injuries requiring medical attention; expresses suicidal thoughts or has made a plan; has attempted suicide; seems unable to keep themselves safe; is in severe distress and unresponsive to support; or has ingested harmful substances. Call emergency services, take them to an emergency room, or contact a crisis hotline. When in doubt, err on the side of caution.

While not all self-harm constitutes an emergency, certain situations require immediate professional intervention. Understanding when to escalate to emergency services can be lifesaving. Trust your instincts - if you're worried about someone's immediate safety, it's better to seek help and be wrong than to wait and risk serious harm.

Medical attention is needed when injuries are severe or require treatment beyond basic first aid. This includes deep cuts that may need stitches, burns, signs of infection in wounds, ingestion of harmful substances, or head injuries from hitting. Even if the person resists, serious injuries require medical care.

Suicidal Thoughts or Behaviors

While self-harm and suicide are different, they can overlap. Research shows that people who self-harm have an increased risk of suicide, particularly if they express hopelessness, begin to give away possessions, talk about being a burden, or say goodbye to loved ones. If someone expresses suicidal thoughts, take it seriously - even if they say they're "just joking."

Ask directly: "Are you thinking about suicide?" Contrary to myth, asking about suicide does not plant the idea - it can actually provide relief and open the door to help. If they confirm suicidal thoughts, ask follow-up questions: "Do you have a plan? Do you have the means to carry it out? Have you set a time?" The more specific their plan, the higher the risk, and the more urgent the need for professional intervention.

How Can I Take Care of Myself While Supporting Someone Who Self-Harms?

Supporting someone who self-harms is emotionally demanding and can lead to burnout, anxiety, and secondary trauma. Take care of yourself by: setting healthy boundaries; sharing the support role with others; seeking your own therapy or counseling; practicing regular self-care; connecting with support groups for caregivers; accepting that you cannot control their recovery; and recognizing your limits without guilt.

Caring for someone who self-harms can take a significant toll on your own mental health. The worry, the emotional intensity of conversations, the helplessness of watching someone you love struggle - these all accumulate over time. If you don't take care of yourself, you risk burnout, which ultimately means you won't be able to support them effectively. Self-care isn't selfish; it's essential for sustainable support.

Start by acknowledging your own emotional reactions. It's normal to feel fear, anger, frustration, sadness, guilt, or helplessness when someone you love is self-harming. These feelings don't make you a bad support person - they make you human. However, these emotions need an outlet. Consider seeing a therapist yourself, both to process your feelings and to get guidance on how to best support your loved one.

Setting Healthy Boundaries

Boundaries are essential for your wellbeing and, ultimately, for the health of your relationship with the person who self-harms. Without boundaries, you risk becoming enmeshed, where your emotional state becomes entirely dependent on theirs. This isn't healthy for either of you. Boundaries might include limits on when you're available for crisis calls, clarity about what types of support you can and can't provide, and space for your own activities and relationships.

You cannot be the sole support for someone who self-harms. This is too much for any one person to handle, and it can create unhealthy dependency. Ensure there are other people involved in their care - family members, friends, mental health professionals. If you're the only one who knows about their self-harm, encourage them to widen their support network.

Remember that you cannot control another person's choices or behavior. No matter how much you love them, how much you try, or how perfectly you support them, their recovery is ultimately their own journey. You can provide support, encouragement, and resources, but you cannot make them change. Accepting this can be painful, but it's also liberating - it releases you from the impossible burden of being responsible for their healing.

Finding Your Own Support

Don't try to carry this alone. Connect with others who understand what you're going through. Support groups for families of people with mental health conditions can provide invaluable connection and practical advice. Many are available online if in-person groups aren't accessible. Talking to trusted friends or family members about your own struggles can also help - you don't have to share all the details about your loved one, but you can share how you're feeling.

Maintain your own life outside of your supporting role. Continue your hobbies, see your friends, pursue your goals. This isn't abandoning your loved one - it's ensuring you remain a whole, healthy person who can offer support from a place of strength rather than depletion. Regular exercise, adequate sleep, and activities that bring you joy aren't luxuries - they're necessities.

What Professional Treatments Are Available for Self-Harm?

Evidence-based treatments for self-harm include Dialectical Behavior Therapy (DBT), which is highly effective in teaching emotional regulation and distress tolerance; Cognitive Behavioral Therapy (CBT) for identifying and changing harmful thought patterns; Mentalization-Based Therapy (MBT); and in some cases, medication to treat underlying conditions like depression or anxiety. Family therapy can also be beneficial, particularly for adolescents.

Understanding the professional treatments available can help you have informed conversations with your loved one and their healthcare providers. The most researched and effective treatment for self-harm, particularly when associated with borderline personality disorder, is Dialectical Behavior Therapy (DBT). Originally developed by Dr. Marsha Linehan, DBT combines individual therapy with skills training groups.

DBT focuses on four core skill areas: mindfulness (being present and aware), distress tolerance (managing crises without making things worse), emotion regulation (understanding and managing emotions), and interpersonal effectiveness (communicating needs and maintaining relationships). Studies consistently show that DBT significantly reduces self-harm behaviors, with effectiveness rates of 60-80% in reducing self-injury frequency.

Other Therapeutic Approaches

Cognitive Behavioral Therapy (CBT) helps individuals identify the thoughts and beliefs that contribute to self-harm and develop healthier patterns of thinking. It's particularly effective when self-harm is linked to specific cognitive distortions or anxiety disorders. CBT is widely available and has strong evidence for treating the mental health conditions often underlying self-harm.

Mentalization-Based Therapy (MBT) focuses on improving the ability to understand one's own and others' mental states. This is particularly helpful for people who struggle to identify their emotions or who have difficulty seeing situations from others' perspectives. Family therapy can address relationship dynamics that may contribute to distress and helps family members learn effective ways to support the person who self-harms.

While there is no medication specifically for self-harm, medications can treat underlying conditions that contribute to it. Antidepressants may be prescribed for depression or anxiety, mood stabilizers for mood disorders, and in some cases, antipsychotics for severe emotional dysregulation. Medication is typically most effective when combined with therapy.

What Does Recovery from Self-Harm Look Like?

Recovery from self-harm is a gradual, non-linear process that looks different for everyone. It typically involves developing healthier coping strategies, addressing underlying emotional issues, reducing frequency and severity of self-harm over time, and building a life worth living. Relapses are normal and don't mean failure. Full recovery is possible, though for some, managing urges becomes an ongoing practice.

Recovery from self-harm is a journey rather than a destination. It rarely happens in a straight line - there will be progress and setbacks, good days and difficult ones. Understanding this can help you maintain realistic expectations and provide steady support even when things feel discouraging. The goal isn't perfection; it's gradual progress toward a healthier way of coping with life's challenges.

Early recovery often focuses on harm reduction rather than complete cessation. This might mean reducing the frequency of self-harm, using less dangerous methods, or building in time between urge and action. While this may seem like "not enough," it's important to recognize these as meaningful steps. As the person develops more coping skills and addresses underlying issues in therapy, self-harm typically becomes less frequent and severe.

Understanding Relapse

Relapse is a normal part of recovery from any behavioral pattern. If your loved one self-harms again after a period of not doing so, this doesn't mean they've failed or that all progress is lost. What matters is how they respond to the relapse. Can they be honest about it? Can they identify what triggered it? Can they get back on track with their coping strategies?

As a supporter, your response to relapse matters. Avoid expressing disappointment or frustration, which can increase shame and make them less likely to tell you in the future. Instead, respond with compassion: "I'm sorry you're having a hard time. Let's talk about what happened and how we can help prevent it next time." Reinforce that relapse is a normal part of recovery and doesn't erase the progress they've made.

Full recovery - meaning a life where self-harm is no longer used as a coping mechanism - is absolutely possible. Many people who once self-harmed regularly go on to live fulfilling lives without it. For some, this means the urges disappear entirely. For others, urges may occasionally arise during stressful times, but they have the skills to manage them without acting on them. Both outcomes represent successful recovery.