Tag Archives: self-harm

Helping youth who self-harm

By Bethany Bray January 10, 2023

A teenager wearing a mask sits on stairs with her chin and hands resting on her knees. The teenager is looking straight head into the camera. A bookbag sits beside the teenager.

Ground Picture/Shutterstock.com

Self-harm behaviors in American youth rose sharply during the peak of the COVID-19 pandemic and continue to be a concern among counselors who work with children and adolescents.

In early 2021, FAIR Health completed an in-depth analysis of insurance claim records to compare changes between 2019 and 2020. The New York City-based nonprofit found the mental health claims for individuals between the ages of 13 and 18 doubled between March and April 2019 and the same months one year later.

That same age group saw a startling increase — nearly 100% — in the number of insurance claims for medical care received for intentional self-harm between April 2019 to April 2020. And the Northeastern United States (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont) saw the highest spike in claims for treatment of injuries in teenagers from intentional self-harm — a 333.93% increase — between August 2019 and August 2020.

This data tracks with what many counselors are seeing in their own caseloads: An increase in young clients who turn to self-harm to cope with the stress and upheaval that came — and continues to come — with the COVID-19 pandemic.

There is a strong correlation between social isolation and self-harm, notes Deanna Dopplick, a licensed professional counselor (LPC) at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury (NSSI) in St. Louis. As hard as it was for children and adolescents to have decreased connection with peers while schools were closed during the peak of the pandemic, it’s been equally challenging for them to return and reintegrate to the social dynamics of in-person school, she says.

Dopplick, an American Counseling Association member, is among the many practitioners who are seeing an uptick in client referrals for self-harm among children and adolescents. Her organization has “struggled to keep up” with the need for services, she says, and unfortunately, many prospective clients sometimes end up on a waiting list. In addition to new clients, Dopplick says she’s also seen an increase in relapses among clients who have returned to self-harm behaviors to cope after making progress in therapy previously.

As more counselors see youth who self-harm on their caseloads, Dopplick urges practitioners to focus on empathizing with these clients and fostering a trusting therapeutic relationship. The worst thing a practitioner can do, she says, is to panic or act fearful when a client discloses the behavior or dismiss it as attention-seeking.

“I have seen clients that have been in therapy for months or even years [before coming to SAFE], and the behavior has been so protected and shameful that they haven’t disclosed it. There is a stigma that self-injury is weird or different or ‘crazy.’ It’s not something that’s easy to open up about,” says Dopplick, who provides individual and group counseling for clients 12 and older. “We [counselors] need to make sure we’re meeting the client where they’re at, humanizing them and validating their experience. … It [self-harm] is so much more common than people think, and it doesn’t make [the client] scary or different. Empathy goes a long, long way with these clients.”

A way to cope

Michael Visconti is a licensed mental health counselor who treats children and adolescents in private practice in Boston. He estimates that one-quarter of his caseload at any time is exhibiting self-harm behaviors — a proportion that rose to roughly 50% during the peak of the pandemic. Many of these clients are referrals for self-harm from a local pediatric medical office.

The youngest client Visconti has counseled for self-harm behavior (in the form of intentional head banging) was six years old, but he finds it’s most common in younger teenagers, ages 12 to 15, he says.

Like Dopplick, Visconti emphasizes that there is a “direct correlation” between social isolation, feelings of hopelessness and self-harm behaviors in youth. “The more isolated an individual is, the less they feel they can reach out to others and express that emotion, so they turn inward,” Visconti explains. “Most often, it’s a maladaptive form of coping.”

While the intense isolation that occurred during the peak of the pandemic has lessened, all the same stressors that youth experienced before the pandemic (such as abuse, neglect or trauma at home, negative body image, social pressures and negative messaging on social media) remain, he notes.

In Visconti’s experience, the reasons that drive youth to self-harm often fall into a few common categories:

  • Managing emotions: When feelings are strong and uncomfortable, adolescents and young clients sometimes find it easier to experience physical pain rather than emotional distress. Self-harm offers an immediate and effective means of emotion regulation in the short term. Visconti says that in his experience, this is the most common pathway to self-harm.
  • Communicating: Some individuals make use of self-harm to outwardly display their emotional pain because they don’t have the means or opportunity to put it into words. This can be especially common among youth who live in invalidating family and home environments, Visconti says.
  • Punishment: Young clients sometimes turn to self-harm to punish themselves and “confirm” and internalize the negative narrative they have about themselves, Visconti says. These clients often believe that they are the problem and reason for their unhappiness, and self-harm is a way to reinforce these feelings. This is common among youth with poor self-esteem and/or a trauma history, he adds. Dopplick also finds that young clients who self-harm often struggle with intrusive thoughts that are intensely negative, such as “I am bad,” “There is something wrong with me” or “I am a disappointment,” so she spends a lot of time focusing on redirecting self-talk with clients at her program.
  • Seeking control: Some young clients turn to self-injury as a means to exert control in their life, albeit in a painful way. It can be a maladaptive way to find autonomy, Visconti explains. This was the especially the case when many youths felt that the “fundamentals of their life had been stripped” away during the pandemic, such as the routine of the school day, social activities, extracurricular activities and other things they enjoyed.

Asking the right questions

The crux of what defines NSSI is the intent behind the behavior, Visconti explains. Self-harm can be an impulsive phenomenon as well as something that is very deliberate, planned and well thought out. Visconti says that it’s not uncommon for him to see young clients who have created a self-harm “kit” for themselves, complete with harming tools as well as items to disinfect and treat wounds afterward.

When assessing for self-harm, counselors should not hesitate to ask clients directly about whether an injury was deliberate to determine intent, Visconti says. He often uses questions such as “Was that [injury] purposeful?” or “Did you place yourself in that setting with the hope that it harmed you?”

That second question can help uncover behaviors that are beyond the common ones that counselors may think of, such as cutting or burning. For example, Visconti once had a young client who slept on a mattress that had a metal spring poking out of it, and he purposely didn’t tell the adults in his life about it because he hoped that it would cut and injure him while he was in bed.

Asking questions about intent can also help uncover behaviors that a client has kept hidden or that escape the notice of peers or adults in a client’s life.

Dopplick has also seen self-injury behaviors that are outside of what a counselor may expect. This includes keeping a (non-self-inflicted) wound from healing, hitting or biting oneself, inserting objects under the skin, ingesting things that the client knows are toxic or dangerous (such as glass or household cleaners), head banging, hair pulling, picking of skin or nails and other behaviors.

In sessions, asking clients questions to determine the frequency and severity of self-harm impulses and actions is vital to understand the context of their behavior and level of risk, Dopplick says. For example, a client who has self-injured twice by a single method (i.e., rubbing themselves with an eraser to the point of burning) will need a different response than an individual who has injured themselves 100 times or uses multiple methods (e.g., cutting with a razor blade, punching walls).

Understanding the full context of a client’s NSSI can help a counselor identify the reasons why they engage in the behavior and, ultimately, personalize and tailor treatment to meet their needs. Dopplick encourages counselors to ask clients a range of questions, including:

  • Have they ever received medical attention for NSSI or needed attention but didn’t seek it?
  • What tools are they using to injure themselves? Do they have access to these tools?
  • How often are they engaging in self-injury?
  • Are their harming behaviors usually impulsive or preplanned?
  • Does anyone else, such as a parent or a friend, know that they’re self-injuring?

“Having the impulse to injure is different than following through with action,” Dopplick adds. “They may have impulses every day but may only injure once per week. It’s something to ask about: How are they managing their impulses?”

She recommends counselors ask clients to keep a log to track situations when they felt the urge to self-harm or engaged in self-harm, which she says can be helpful in therapy because it can shed light — both for the client and the clinician — on patterns. Dopplick encourages clients to record what they were doing and feeling before, during and after an urge to self-injure to help identify triggers.

Although NSSI is distinct from suicidality, the counselors interviewed for this article note that it’s important to assess clients who self-harm for suicidal intent because the two issues can sometimes overlap.

Visconti uses the Columbia-Suicide Severity Rating Scale and recommends it as a helpful way to screen both for suicidality and self-injury and parse out the intent and severity of a client’s behavior. The tool’s questions can help determine how chronic a client’s behavior and feelings are, he explains, and it can be easily used with many different client populations and treatment settings.

Discussing self-injury with a young client can be uncomfortable or worry-inducing for a clinician, Dopplick and Visconti admit. However, it’s vitally important for counselors to complete a thorough assessment to determine a client’s level of risk without becoming panicked and jumping to crisis response, such as talking about hospitalization.

“If you [the counselor] seem scared or overwhelmed or go straight into crisis mode, you won’t get all the information you need from the client,” Dopplick stresses. And “that will make them very hesitant to disclose self-injury again.”

She encourages counselors to keep an open mind when asking clients about their self-harm behaviors. Making assumptions about the factors that contribute or the reasons why they are engaging in NSSI “is the best way to shut down the conversation,” Dopplick adds.

Instead, “see the client as the expert on themselves and their behavior. Do not criticize, minimize [the behavior], come off in a punitive way or assume they’re doing it for attention or because their friends are doing it,” she stresses. “Really put the client in the driver’s seat instead of coming at them with assumptions.”

Finding healthy ways to cope

At its core, NSSI indicates that a client has unmet needs, Dopplick says. A counselor’s role then is to help the client identify and understand those needs and find ways to meet them without turning to self-harm.

“No one self-injures for no reason; there’s always an underlying reason, a function,” she notes. “For most clients, it [self-harm] is something that they’re hiding, something just for them, something that ‘helps’ them.”

Dopplick says that the counseling groups she leads for self-injury spend the majority of the time talking about the context and circumstances surrounding their self-harm, rather than the actual behavior. For young clients, this often includes the pressures their parents put on them or stress related to school or social relationships.

“We talk about the why and how more than the what,” Dopplick says. “The self-injury is not the actual problem; it’s what’s underneath it. All the underlying stuff — the why — is the problem, and [counselors] can miss the boat if [they] don’t explore it.”

Paige Santmyer, an LPC who works with teens and adults at a Christian counseling practice in the Atlanta area, agrees that helping clients identify what triggers their urge to self-harm is an important first step, followed by creating a plan to replace the behavior with healthier options. It also helps to identify the perceived “reward” they seek in self-harm, she says, to tailor a client’s treatment plan and coping mechanisms.

For example, if a young client struggles with feeling numb and turns to cutting themselves to feel something, Santmyer says she would teach the client mindfulness and guided imagery techniques that can help them connect to how they’re feeling. Or, depending on the client, they might respond to something creative such as using virtual reality to “go” hiking or zip lining to redirect and energize themselves, she suggests.

Young clients will need activities and techniques at the ready to replace the urge to self-harm; planning ahead is key. Santmyer brainstorms with clients to identify ways they can seek connection and soothe themselves when needed, such as doodling or drawing or talking to an accountability partner.

She also finds it helpful to have young clients create a “distraction box” filled with special or favorite items that can help to self-soothe and take their minds off the urge to self-harm. These items can include art, knitting or crochet supplies, essential oils, a favorite lotion, coloring or puzzle books, pictures of loved ones, an object with beads for counting or a kaleidoscope to look through. (For more on creating self-soothing kits with clients, read the Counseling Today online exclusive “Regulating the autonomic nervous system via sensory stimulation.”)

Similarly, Visconti says he focuses on helping young clients who self-harm find ways to redirect themselves away from the urge to injure. He gives clients a worksheet with 100+ ideas from Matthew McKay, Jeffrey Wood and Jeffery Brantley’s The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance to spark ideas and keep for future reference. Depending on the client’s age and needs, activities could include playing video games, visiting a friend, eating their favorite flavor of ice cream, writing a song, using an app to learn a new language, getting a haircut or painting their nails.

Managing distressing emotions

The counselors interviewed for this article agree that while clinicians need to tailor their work to fit their clients’ individual needs, many young clients who self-harm will need some combination of treatment that challenges negative self-talk and strengthens distress tolerance and emotion recognition and regulation.

Santmyer says that it’s common for young clients who struggle with NSSI to be disconnected from and confused about their emotions.

She focuses on emotion recognition with clients by asking them to think about where they feel strong emotions in their body and prompting them to talk about what it feels like and how they usually respond to those sensations. She also finds cognitive behavior therapy (CBT) helpful to guide clients to explore, challenge and reframe the fears and negative core beliefs that drive feelings such as worthlessness or perfectionism that trigger an urge to self-injure.

“Helping them understand and name the emotion they are feeling helps clients feel more in control of themselves instead of feeling compelled to manage the sensation itself through self-injury. Counselors can also use CBT to build insight into how emotions are giving them messages, how they can interpret them in positive or negative ways, and how those interpretations lead them toward or away from self-injury,” explains Santmyer, an ACA member. “Ultimately, clients will need to understand how they are perpetuating their self-injury cycles and practice changing their negative thoughts to change their self-harming choices into more thoughtful and healthy responses.”

Santmyer and Visconti also noted that dialectical behavior therapy (DBT) can be especially helpful to use with young clients who self-harm because of its focus on emotion regulation and distress tolerance. (Santmyer and Visconti are not certified in DBT but have studied it and draw from the method in their work with clients.)

DBT is a good fit for this client population because it’s practical and effective in a short amount of time and it teaches much-needed skills and coping mechanisms to manage stress and tolerate uncomfortable feelings, Visconti notes. In fact, he says he’s seen DBT techniques spark growth and healing in self-harm clients right away because of the skill-building component.

However, DBT is most helpful for clients who self-harm as an emotional outlet, rather than those who use the behaviors to communicate or exhibit their emotional pain, he adds.

Santmyer finds that the ACCEPTS skill from DBT is particularly helpful to strengthen clients’ ability to overcome distressing emotions and situations without turning to self-harm. This tool guides clients to think about or engage in:

  • Activities: Do something that requires thought and focus, such as writing in a journal, to shift their attention away from distressing emotions.
  • Contributing: Do something that involves focusing on other people (e.g., sending a card, asking a loved one about their day, doing volunteer work).
  • Comparisons: Put their situation in perspective by comparing it to something more painful or challenging, including thinking of a time when they were in greater distress and got through it.
  • Emotions: Find a way to disrupt the emotion they are feeling (e.g., angry, sad) and replace it with a different or opposite emotion (e.g., going for a walk to calm oneself, watching a happy movie).
  • Pushing away: Use a technique such as guided imagery to block painful feelings from their mind and delay the urge to self-harm.
  • Thoughts: Use a strategy to shift one’s thoughts to something neutral (e.g., counting backwards, reciting song lyrics, naming objects around them that start with a certain letter of the alphabet).
  • Sensations: Engage in activities that trigger safe sensations that distract them from distressing emotions (e.g., eating something spicy, feeling the water on their body during a shower).

Trust and validation

Getting to know the client and tailoring treatment to their individual needs must take priority when counseling youth who struggle with NSSI, Dopplick says. She suggests that practitioners first find ways to connect with clients — particularly those who have been referred to counseling specifically for NSSI — and talk about topics other than self-injury to forge a trusting relationship.

Believing the client and validating their experience and pain should be the counselor’s No. 1 priority, she stresses. Only then can a counselor begin to identify and delve into the reasons underneath their self-injury.

“Often [these clients] feel that no one understands or validates their pain, and they are compelled to continue self-harming as a way to express in their body what they feel they cannot express verbally,” Santmyer says. “The validation and compassion of the therapist will bring the safety that young clients need to explore the drivers of self-harm.”

Dopplick finds that she’s sometimes the first adult to tell a young client that she understands why they are distressed to the point of needing to self-harm or to emphasize that they’re not weird or “crazy” for engaging in NSSI. After validating the client’s experience, she explains that she can help them find other ways to cope.

It’s vital for counselors to keep an open mind and accepting demeanor with these clients, Dopplick stresses. “There’s a huge difference between expressing your concern in a caring way, rather than asking 1,000 questions and focusing on” a client’s self-harm behaviors, she says. “It’s important to approach it with curiosity. … They know themselves and know what this behavior does for them; you just have to help them figure that out, and then build off of that to get more information.”

When working with young clients who self-harm, Visconti says he makes sure to acknowledge how hard it is to disclose and discuss such a painful and deeply personal topic. He thanks them for trusting him with such vulnerable information and feelings. “I empathize [with clients], commiserate and then try and bring about a sense of hope and preservation,” he adds.

The most important technique a counselor can use with these clients is the therapeutic relationship itself, Visconti says.

He admits that young clients who engage in self-harm can be challenging, not only because it’s an uncomfortable topic to address but also because they often have multiple presenting concerns or mental health challenges.

However, he pushes back against the misnomer that talking about self-harm in therapy can increase the behavior, retraumatize or cause emotional harm for a client. Counseling involves delving into many different types of painful topics, he says, and the key is for practitioners to handle it with openness and warmth.

“The long-term benefits greatly outweigh that distress,” Visconti emphasizes. “It’s so crucial to the betterment of their client, and you’re not going to increase the likelihood [of NSSI] by talking about it — it doesn’t work like that.”

Challenges that can co-occur with nonsuicidal self-injury

Depression and anxiety are the most common diagnoses that can co-occur in young clients who engage in nonsuicidal self-injury (NSSI). However, there are many other challenges that individuals may struggle with simultaneously.

There is a high correlation between NSSI and eating disorders, as well as clients who have experienced trauma, particularly sexual trauma, as self-harm can be a way for these individuals to seek control, disconnect or cope with painful feelings, trauma flashbacks or the stress of continuing to live in an abusive environment.

It also can co-occur with obsessive-compulsive disorder in clients who use self-injury to satisfy urges for repetitive behaviors to manage or communicate distress. This can also be the case for individuals with autism.

“It’s very effective to disconnect: To disconnect with their brain, with their body and overwhelming feelings, and this [self-injury] gets it to stop. But that’s also one thing that makes it hard to stop doing,” says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for NSSI in St. Louis. “A lot of people think of self-injury as this impulsive thing, and it can be, but it also can be very obsessive. If they [a young client] can’t manage their stress at school, they may be thinking all day about injuring once they get home.”

The relief and other satisfactions that an individual seeks from self-harm lessen over time, which sometimes causes individuals to increase the self-harm behaviors and, eventually, turn to other risky behaviors, such as sexual promiscuity, restrictive eating or using substances, to seek similar feelings of reward or relief. So counselors who work with clients who disclose self-injury behaviors (or a past history of NSSI) should also screen for substance use, suicidal ideation, eating disorders, behavioral addictions and other high-risk or destructive behaviors.

This information came from an interview with Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives (selfinjury.com).

Supporting parents of young clients who self-injure

Counselors who work with children or adolescents who self-injure are in a position to offer support to adults in the client’s life who are misunderstanding or anxious and upset about the child’s behavior.

Understandably, parents often panic and experience intense worry when they find out their child is self-harming, says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury in St. Louis. Often, parents’ first response is to enact punishment, such as taking the child’s cellphone away to cut off contact with friends or locking up all the sharp objects in the home.

However, this won’t stop the child’s self-harm behavior — it can actually increase it, Dopplick says. A punitive response from the adults in a client’s life will only cause the child or adolescent to feel even more shame about their self-harm, and it can lead them to engage in harming behaviors that are more hidden and secretive. This includes injuring themselves in ways that won’t leave a mark or on parts of the body that are usually covered by clothing.

It’s also not helpful for parents to reward a child for going a length of time without injuring themselves, she adds. Counselors can offer psychoeducation to parents on why the punishment-reward cycle is not effective in situations of self-harm, and they can provide healthier alternatives.

“We have to remember that it [self-harm] is a coping mechanism. It’s not a healthy one, but it does not mean that the child is ‘bad,’” seeking attention or acting out, Dopplick stresses.

She finds that the book Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones by Janis Whitlock and Elizabeth Lloyd-Richardson is a helpful resource to recommend to parents. The book offers guidance on ways parents can talk to their child about self-harm and support them in a healthy way. (Whitlock, one of the co-authors, is the director of the Self-Injury & Recovery Resources research program at Cornell University; Dopplick notes that Whitlock’s entire body of research can be helpful to counselor practitioners who want to learn more about the topic of self-harm.)

Parents often jump to the assumption that self-harm behaviors mean that their child is suicidal, says Michael Visconti, a licensed mental health counselor who treats children and adolescents in private practice in Boston. Research indicates that the majority of individuals who self-harm do not have suicidal thoughts, he notes.

So counselors can educate parents on the differences between suicidal ideation and self-injury and assure them that although self-harm behaviors are concerning, they don’t necessarily mean that their child wants to end their life, Visconti stresses.

Bethany Bray is a former senior writer and social media coordinator for Counseling Today.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Responding to the youth mental health crisis in schools

By Bethany Bray July 25, 2022

Late last year, U.S. Surgeon General Vivek Murthy issued an advisory to call attention to what he described as a “youth mental health crisis.” Depression, suicidality and other mental health challenges have been on the rise among American youth in the past decade, but Murthy believes the stressors and isolation of the COVID-19 pandemic exacerbated an already alarming situation.

In a June interview with ABC News, Murthy acknowledged that the crisis is ongoing, saying, “Ultimately, we will know when we’ve reached the finish line when they’re [American youth] doing well and they tell us they’re doing well and when data tells us that as well.”

Murthy’s advisory called attention to a concerning situation that school-based counselors continue to witness firsthand. American students are experiencing an increasing severity and prevalence of mental health challenges that range from self-harm and disordered eating to underdeveloped social and emotional regulation skills.

Students are trying to learn among a multitude of storms. America continues to struggle with the ongoing dual crises of racial injustice and the lingering COVID-19 pandemic. And on top of that, divisive issues related to schools have been making news headlines lately, including laws created to target transgender youth, arguments about critical race theory and school curriculum, and despair and finger-pointing after the deadly school shooting in Uvalde, Texas, which claimed the lives of 19 elementary school students and two teachers. 

It all adds up and is affecting the day-to-day lives of children and families. 

With a problem so large, it’s going to take more than school-based counselors to reverse the concerning trends in youth mental health. School counselors are on the front lines of this storm, but they also need buy-in, support and collaboration from school administration and staff, parents, community mental health professionals and the community at large.

Distress in students

Jennifer Akins, a licensed professional counselor (LPC) and president of the Texas School Counselor Association, noted that schools across her state are seeing both increased prevalence and severity of depression, anxiety, self-harm, suicidality and eating disorders among students. This has prompted statewide agencies to collect and track data on student mental health, including self-harm, to inform interventions and programs to be deployed in the public schools, Akins says.

“These are not new issues for us, but the thing is the numbers are so much greater,” says Akins, the senior director of guidance and counseling for the McKinney, Texas, public schools. “A huge area of need right now is emotional regulation. They [students] are just not as skilled right now at managing strong feelings. … Students who are experiencing thoughts about self-harm are more often advancing those thoughts into action. They now have thoughts, plus a plan, plus action.”

Texas school counselors are also reporting an increase in self-harm in young students at the elementary level, Akins adds.

Akins is far from alone in what she is seeing. The school-based counselors interviewed for this article report similar rises in self-harm, depression and other mental health challenges among their student populations. Many of these issues were present before the pandemic, but the isolation and lack of social interaction the students experienced while learning remotely during the first years of the pandemic weakened students’ social skills and their ability to regulate their emotions and cope with distress. According to several of the school counselors interviewed for this article, students’ social media use is also a factor that often makes these issues worse.

Jessica Henry has been a high school counselor for 15 years in the Akron, Ohio, area, and she says she’s never seen so many students struggling with suicidal ideation, self-harm, depression, anxiety and panic attacks.

Students are experiencing a lack of resilience and continue to struggle to adjust to in-person school, and for some, this includes developing unhealthy coping mechanisms such as self-harm, Henry says. Small problems that could otherwise be overcome often spiral into “the end of the world” for students, adds Henry, a licensed school counselor in a seventh through 12th grade school in Ashland, Ohio.

For some students, home can be a tumultuous atmosphere and a source of stress, so school functions as a safe place, which they lost when schools switched to at-home learning during the pandemic, notes Henry, a licensed professional clinical counselor and supervisor.

Jessica Holt, an LPC and counselor at a middle school in metro Atlanta, has noticed that in addition to self-harm, depression and anxiety, interpersonal problems, such as bullying and conflict with peers, have become more prevalent recently. Her school has seen an increase in the number of students requesting one-on-one counseling on their own, as well as referrals from teachers and school staff for students who need someone to talk to. There has also been an increase of students who are struggling with sexuality or gender identity issues or who feel like they don’t fit in, she says.

Even though most schools have returned to in-person instruction, the effects of being out of the school environment continue to affect students’ mental health, particularly their self-esteem, social skills and anxiety, says Holt, a member of the American Counseling Association. They are still out of practice with navigating classroom dynamics and making friends.

In Holt’s experience, many parents overcompensated and became more involved in their children’s lessons while they were at home for virtual learning. Parents would log in during virtual learning and check their child’s grades, monitor their work and send messages to teachers. As a result, Holt has noticed that students are struggling with autonomy and self-esteem now that they have returned to in-person classes. Parents are more likely to be the one to message the school when a student is failing, she notes, rather than the student being proactive and asking to make up missed assignments or for extra help.

“Kids don’t have problem-solving skills because things have been done for them. They don’t know how to cope when they are in distress,” Holt says. “One thing that has come out of the pandemic is [problems with] accountability. Students are not taking responsibility because their parents have taken everything on. … That self-advocacy piece is not there for a lot of students.”

Early intervention

Derek Francis, manager of counseling services for the Minneapolis Public Schools, says that his district will be doubling the number of elementary school counselors this fall. Counseling staff at the elementary, middle and high school levels in Minneapolis have also been leading more small groups for students to focus on social-emotional learning, managing stress, anxiety and other mental health challenges.

Minneapolis students are struggling not only with self-esteem, peer conflict, anxiety and other mental health issues but also with discrimination and bias based on racial, sexual and other identities, including negative interactions on social media, says Francis, who co-authored a chapter on proactively addressing racial incidents in schools in the ACA-published book Antiracist Counseling in Schools and Communities. In response, Francis’ school district has enhanced counseling services (including small groups) and weaved mental health discussions with a cross-cultural focus into classroom lessons across grade levels. It’s powerful when students hear that their peers are feeling some of the same anxiety and distress they are experiencing and are able to talk about it openly, says Francis, who works in the Minneapolis Public Schools’ Department of College and Career Readiness.

The Minneapolis schools are also taking an early intervention approach to mental health. Recent years have shown that elementary students can benefit from learning coping skills that help them regulate and calm themselves and deal with strong emotions, Francis says. So the district has been teaching young students how to identify when they’re becoming overwhelmed, name their feelings and use skills to calm themselves, such as breathing techniques, as well as letting them know whom they should contact within the school for additional help.

Self-regulation in a young student can mean the difference between moving on from a negative interaction with a peer on the playground or remaining upset the entire day, says Francis, an ACA member. Teaching young students these skills during elementary school may keep them from carrying over or forming difficult or unhealthy behaviors, such as skipping class, into middle or high school.

“The younger we can help kids know how to regulate their emotions and talk about their feelings, the better,” he stresses.

As manager of all the school counselors in the Minneapolis Public Schools, Francis often goes into classrooms to speak with students. During a recent session on “the power of words” with third, fourth and fifth graders, he sparked discussion by asking students for examples of incidents when they’d heard an “ouch” (hurtful) word and ways to respond when they are the recipient of or witness to an ouch word. The students had plenty of experiences with ouch words, including one kid who had been ridiculed for his lisp.

Francis then focused the conversation on social skills, empathy and ways to connect with people who come from different backgrounds. His overarching message to the students was that school should be an inclusive place, says Francis, a professional development specialist with Hatching Results, a company that provides training and continuing education for school counselors, administrators and school districts.

Francis says his district intentionally approaches hate and bias incidents in the same way they treat fire drills: It’s something for staff, students and parents to prepare for. That way, when something does happen, everyone knows how to talk about it, respond and connect with resources. 

The Minneapolis schools have also focused on the negative implications that social media use can have on student mental health. It’s become clear that students are saying hurtful things to each other online, not only on social media platforms such as TikTok and Snapchat but also via the chat feature on video games, group text messages and other avenues, Francis notes.

Adults don’t often realize how much of students’ lives are spent in the digital world, he says, and parents and students alike are not often aware of the connection between social media use and how a person feels about themselves. Many students do not have a parent or adult who monitors their dialogue on social media or helps them know when to log off or disregard negative comments, he adds.

“[Students’] brains are not developed yet to know how their words impact other people. It’s an area that needs a lot more development after the pandemic,” Francis continues. “The [effects of the] isolation of the pandemic, when paired with the negativity of social media, can really distract them from seeing positive things about themselves. We have to be mindful of the impact of screen time on students’ mental health. … It really impacts the school environment when it’s unaddressed.”

Forging connection

Holt and the other school counselors at her Atlanta-area middle school coordinate their schedules so they can visit and speak to the classrooms each fall. These visits serve as an opportunity to survey students on their mental health needs, and they also allow students to meet the counselors and learn more about the schools’ counseling programming.

The survey data they collect during these classroom visits informs the counselors’ focus for the year (e.g., the need for small groups to help students with anger, parental separation, grief or other issues) and also helps them identify and connect with individual students who are at risk, Holt explains.

Tracking student concerns and tailoring an appropriate counseling response are even more vital as mental health difficulties are on the rise.

Three students at Holt’s middle school have taken their own lives in the past five years. Part of the district’s response to the suicides, as well as to the overall increase of mental health needs, has been to establish a program that installs school-based therapists to provide long-term therapy for students. This year, Holt’s district has increased the number of school-based therapists to meet  the demand.

Holt’s school has also adopted several peer-based programs, including one that pairs established students with peers who are new to the district and another that trains students in suicide prevention and how to respond and connect a peer to appropriate help when they notice suicidal ideation (e.g., observing evidence of cutting in a peer as they change clothes for physical education classes).

The peer programming, counselor classroom visits and other recent initiatives are aimed at preventing students from falling through the cracks and help the counselors keep their finger on the pulse of the school, Holt explains. And it’s had a positive impact on school culture.

Like Holt, Henry feels that counseling staff need to be more visible and involved in their schools to respond to the recent rise in mental health needs. Now more than ever, school counselors need to get creative and set an example for other school staff by taking the first steps to forge connection with students, Henry says.

Long hours and heavy workloads leave teachers and counselors prone to burnout, but students also suffer when teachers and school staff focus on just getting through the school day and lose sight of the emotions and issues that students are dealing with beyond academics, stresses Henry, who is co-author of the 2019 book Mental Health in Our Schools: An Applied Collaborative Approach to Working With Students and Families. School staff who don’t take the time to connect with students, she says, risk not being able to recognize when a student is having an “off” day or exhibiting uncharacteristic behavior that indicates they need extra support.

School counselors can take steps to prevent this by encouraging teachers to spend time bonding with students at the start of the year, rather than diving into rigid topics such as classroom rules and expectations, Henry says. She notes that icebreaker activities, such playing bingo or prompting discussions about students’ favorite television shows or rides at a local amusement park, can make a big difference in fostering connection.

“And with that [activity] comes so much more dialogue,” she adds.

Henry also encourages counselors to be proactive and make their services known during team meetings and trainings among school staff. By emphasizing that their “door is always open” for collaboration when a student is struggling behaviorally or academically, counselors can help remind teachers that they are an important resource that can help address the underlying reasons for disruptive behavior or failing grades, such as anxiety, self-esteem issues or food insecurity at home. 

Henry says that improving student mental health and school culture is about school counselors “being present, being around [the] teachers and being around students as much as possible,” including in the hallways and at lunch. “And invite teachers to collaborate with you when a student seems ‘off,’” she adds. “When an adult reaches out, little things like that can change a kid’s life and make them feel like someone does care.”

Henry often offers to serve as a mediator between a teacher and a student when behavioral issues or conflict arises in the classroom. “I sometimes meet with a teacher behind the scenes to say, ‘Have you tried this?’ or ‘When I worked with this student, here’s what worked, here’s what he responded to,’” she explains. “It’s just like a [counseling] treatment plan; if something is not working, we move on and try something else.”

It’s easy for school staff to focus on what a student is doing wrong, she notes, but it’s more helpful to focus on what they’re doing right and emphasize their strengths. Offering students creative options beyond discipline and exploring the reasons why they’re struggling is key.

“We need to meet kids where they are,” says Henry, who counsels individual clients part-time at a private practice in addition to working as a school counselor. “Some of these kids just want to be heard. Just listening to what they have to say and not judging them makes a big difference. They need to feel like people [school staff] care.”

Barriers to behavioral health care 

School counselors are often the first mental health professional a student who is struggling with mental illness comes in contact with, notes Stephen Sharp, a school counselor at a middle school and coordinator for K-12 school counseling services in the Hempfield School District in the suburbs of Lancaster, Pennsylvania.

However, many students need long-term outpatient therapy that would not be appropriate or feasible for school counselors to offer. When students and families face barriers to access behavioral health care, it only adds to the increasing student mental health needs that schools are facing, notes Sharp, a member of the American School Counselor Association (ASCA) board of directors. 

The issue that Sharp says he finds most challenging is that for many of his students, all of their mental health support “begins and ends at the school walls.”

Sharp says he’s seen students go months without needed treatment because they were put on a waiting list for an appointment with a local mental health provider or they lack insurance or the ability to pay for treatment not covered by insurance. In some cases, undertreatment or lack of preventive treatment has led to student hospitalizations, he adds.

The biggest need for my students is access to ongoing behavioral health services,” he says. “The reality is that it [the gap in services] creates a disproportionate burden on the schools. Not just on school counselors but teaching staff as well.”

Sharp’s school district has a strong partnership with a local behavioral health provider who provides school-based services for students. However, he says that many students are not able to take advantage of the service. Both lack of insurance and limited coverage are barriers to treatment for students, he notes, but the latter is more pervasive. Students may have health insurance, but their plan may not cover certain services such as school-based therapy or virtual therapy, he explains.

There is also a shortage of behavioral health care providers just at a time when there is an increased demand for services. Sharp says that his school struggled this year to find a qualified school-based therapist to hire in addition to school counseling staff.

Sharp’s district is not alone in this phenomenon. Francis says that community mental health agencies in Minneapolis are also full and have waiting lists. In Texas, community resources that would otherwise provide support for families outside of schools, such as social service organizations, civic centers and nonprofit programs, are declining — and in some areas are nonexistent, Akins notes.

The pandemic revealed the cracks and flaws not only of our education system but also the health care and mental health care systems, Sharp notes.

“We are in a behavioral health care crisis, not just in the state of Pennsylvania but nationally as well, and it leads to a lack of access to care. Certain areas (e.g., rural) have always had a lack of care, but it’s gotten so much worse,” Sharp says. “All of this is really disheartening and challenging, but it’s also something that we absolutely as a profession and a society need to be talking about. What level of advocacy and coordination are we going to do to address these concerns?”

Sharp says the past year has been the hardest year yet for him professionally. But at the same time, he sees opportunity ahead.

One of the lessons gleaned from Hurricane Katrina, Sharp notes, is that a coordinated response works best in times of crisis, especially when there are financial strains and staffing limitations. There is an opportunity for national-level organizations such as ACA and ASCA to offer guidelines, training and other programming to address the rise inyouth mental health concerns, he says. And there is also opportunity for multidisciplinary collaboration. For example, the Pennsylvania School Counselors Association (PSCA) is working with the Pennsylvania chapter of the American Academy of Pediatrics to address the barriers to care in their state, he notes.

Support from professional organizations as well as collaboration among and across helping professionals at the local, state and national levels “makes things better but also makes us [individual counselors] feel like we’re not the only ones pushing against a brick wall,” says Sharp, a past president of PSCA. “The more innovative that we can get and share stories of success, those are the types of things that will lead to something better after this.”

All hands on deck

As a school counselor, Holt says that she sometimes thinks of her role as a “connector” between students and families and wraparound resources that can help meet their needs outside of school, including mental health services. However, she advises school counselors to only share resources that they are familiar with and have vetted to ensure that they offer quality services.

It’s helpful, Holt says, when a professional counselor contacts her school to let them know they offer group or individual services that are well-matched to their student population. She also recommends counselors have a list of local providers that they can offer to teachers and school staff who, like counselors, sometimes find themselves overwhelmed and in need professional support.

Holt encourages community counselors to connect with their local school counselors, and vice versa. “Having that connection from community mental health to the schools is very important,” Holt says. “The more resources that we [school counselors] know about, the more referrals we can do for our parents and students. If we don’t have connections in the community, it makes it harder. Being able to know that we have partners in the community and knowing what’s available is helpful.”

Akins agrees that partnerships between school and community resources will be key in addressing the recent increase in youth mental health needs. However, community counselors need to recognize that establishing helpful collaboration takes time and patience.

There are a lot of practical components that have to fall into place before a school can adopt a new program or resource, Akins notes. “Instructional minutes are very precious,” she says, so school officials cannot always justify using class time for mental health programming.

Akins suggests that community counselors get to know the unique needs of their local school district, as well as what has and hasn’t worked for other schools, before contacting their school to offer help.

In times of crisis, “sometimes people who are coming from the [nonschool] mental health community think ‘we don’t have time to waste.’ That’s true, but processes are in place for a reason (i.e., student safety),” Akins says. “Taking the time to really connect with your district and plan and develop a formal partnership will be a lot more successful than emailing a principal to ask, ‘Can I come in and do XYZ?’”

Sandi Logan-McKibben, a clinical assistant professor and school counseling program director at Sacred Heart University in Connecticut, asserts that counselors have an ethical responsibility to know what mental health and other wraparound resources are available in their area for clients and students.

She believes in this idea so strongly that she assigns her school counseling students a community mapping project each year. The students are charged with finding resources within the school district where they are working as a counseling intern and then overlaying those resources on a Google Maps image of the area. Students’ maps include not only mental health services but also after-school, tutoring and mentorship programs; organizations that help with food insecurity, homelessness or immigration services; nonprofit or faith-based organizations; and other institutions. 

This mapping project can be helpful for community and school-based counselors, whether they are students or not, adds Logan-McKibben, an ACA member.

She also recommends counselors find and help fill gaps in needed services. This can include anything from advocating for funding at a school board meeting or partnering with an existing nonprofit to expand services to contracting with a local university to offer pro bono counseling services for school students.

“It only takes one person to enact something and prompt change,” says Logan-McKibben, a former school counselor who lives in Florida and teaches virtually at Sacred Heart. “Find out what the actual needs of your community are. Don’t make assumptions. You don’t know unless you reach out.”

Counselors in all settings have a common skill — resourcefulness — and they need to draw on that skill to meet students’ needs in this time of crisis, Logan-McKibben says. This calls for counselors to work with a preventive, proactive and collaborative focus.

“The most important thing for all professional counselors to know is that we’re all in this together. Any kind of school crisis is really a community crisis,” she says.

Sharp agrees that counselors have a role to play in advocating for support for mental health care “both in and beyond the walls of the school.” This is a time to be concerned, he admits, but it’s also a time for meaningful work to be done.

“We also need to acknowledge the work that is being done and was done before [the situation became a crisis]. That work mattered before, and it matters now,” Sharp says. “Whether it’s school counseling or clinical counseling work we’re doing, it’s a sensitive time for the profession, … but [it’s] also a time to be mindful and reflective of victories and lessons learned. Also, [counselors should] take the time to celebrate. Celebrate the work our clients and students have done and use that to make the profession better.”


The influence of social and political issues on youth mental health 

Adults have been making a lot of decisions lately that not only create news headlines but also affect youth mental health, including a law aimed at making it easier for teachers to carry firearms in Ohio schools and the controversial Florida law — dubbed “Don’t Say Gay” by its opponents — that banned classroom instruction about sexual orientation or gender identity.

For school counselors, these issues are more than soundbites on news programs. They affect their students and families and add to the already complicated work school counselors are doing to combat a rise in suicidality and other mental health concerns in American youth.

Jessica Henry, a high school counselor in the Akron, Ohio, area, says she’s had coworkers who have refused to use a student’s preferred pronouns. “Not only is that unethical and has legal ramifications, it’s [also] very difficult to hear when a teacher says, ‘I’m not doing that,’” she says.

Henry, a licensed professional clinical counselor, feels that schools (and school counselors) should take a proactive role to address controversial issues rather than avoiding them. Students, parents and educators need to hear about topics such as racial injustice and LGBTQ+ inclusion, she says.

“We have to address the bigger picture of what is going on in our world. It’s about getting your administrators and superintendent to understand that inclusivity is vital — and in turn, will affect academics,” Henry explains. “It goes back to [asking], ‘Does every kid feel safe in their school?’ ‘Does every kid feel like themselves in their school?’ If even one student says ‘no,’ we’ve got work to do.”

Part of this work also involves the need for counselors to have the humility to recognize their biases, says Derek Francis, manager of counseling services for the Minneapolis Public Schools’ Department of College and Career Readiness. The majority of the counseling profession is white, yet the majority of many school populations are not, he notes.

“We need to be mindful of our biases. … It takes laying down your privilege and learning, open listening and connecting,” says Francis. “Ultimately, we’re trying to build trust when we’re doing counseling. We want all people to know that we have positive regard for them, and we need to come in [with] the right [unbiased] mindset to help the person in front of us.”

The growing polarization of political and social issues in America has also led to distrust of public institutions such as schools, says Jennifer Akins, a licensed professional counselor and president of the Texas School Counselor Association. She’s seen this mistrust spiral into parents equating terms such as “social-emotional learning” with critical race theory.

“We [school counselors] have been working on mental health issues and school safety for a long time, and many districts have integrated mental health and social-emotional learning [into the curriculum]. There is a segment of the public that has developed a mistrust even of those words, ‘social-emotional.’ They feel that things like mental health don’t really have a place in public education or are inappropriate. That stigma adds to some of the [mental health] needs we’re seeing in students. It’s disheartening,” says Akins, the senior director of guidance and counseling for the McKinney, Texas, public schools. “There’s very little disagreement that parents want to send their child somewhere where they’re cared about and where they’re safe. But the initiatives and programs that help enhance those things are the very things that they are scared into thinking are harmful and terrible.”

One way to reduce these patterns, Akins says, is for school counselors to make transparency and communication with parents about programming a priority, as well as involving parents in the creation of programs as much as possible.

She suggests that school counselors focus on messaging that emphasizes common ground: We all want children to feel connected, to belong and to feel safe, she notes, so open communication about what a school is doing for student mental health — and why you’re doing it — can be helpful. “It’s just a matter of peeling back some of the layers of misinformation,” Akins says.



Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Self-injury: An overview for counselors

By Lauren Appel September 16, 2020

The challenges that students face today can be complicated and overwhelming, causing some youth to resort to self-injury to cope with the stress. According to a study by Martin Monto, Nick McRee and Frank Deryck (published as “Nonsuicidal self-injury among a representative sample of US adolescents, 2015” in the American Journal of Public Health), 1 in 4 girls and 1 in 10 boys will self-harm.

From my experience as a school counselor, I have found that the presence of self-injury often indicates significant underlying emotional issues. Given these realities, I believe it is more important than ever for counselors to familiarize themselves with this dilemma. This overview is intended to walk through what self-injury is and isn’t, who tends to be affected and how to intervene.

What is self-injury?

Self-injury, also known as nonsuicidal self-injury (NSSI), can be defined as deliberate, self-inflicted harm to body tissue without suicidal intent. This does not include behaviors that are socially accepted, such as piercings or tattoos. This definition is based on E. David Klonsky’s research presented in “The functions of deliberate self-injury: A review of the evidence,” published in Clinical Psychology Review in 2007.

NSSI includes, but is not limited to, cutting, burning, biting or scratching the skin, head banging, punching and pinching. Common injury sites include the hands, wrists, stomach and thighs, although injuries can occur anywhere on the body.

Who self-injures?

According to data taken from Jennifer Muehlenkamp and colleagues’ 2012 study, “International prevalence of adolescent non-suicidal self-injury and deliberate self-harm,” published in the journal Child and Adolescent Psychiatry and Mental Health:

  • 1.3% of children ages 5-10 self-injure
  • 17% of adolescents self-injure (this figure is high because it includes those who have self-injured only once)
  • 5% of adults self-injure

Overall, females have been reported to self-injure more than males. They tend to prefer cutting more than any other means of self-injury, according to Janis Whitlock and colleagues’ 2011 study, “Nonsuicidal self-injury in a college population: General trends and sex differences,” published in the Journal of American College Health.

Although males are reported to self-injure less often, it is possible that this is being underreported or that the self-injury is hidden behind behaviors deemed as “more masculine.” For instance, males are more likely to deliberately bruise or cause abrasions to themselves by punching walls or instigating fights to have others hurt them.

This aligns with the incorrect perception that males have to demonstrate a certain caliber of “manliness” and that the only acceptable emotion for them to feel is anger. I have had male students who said they would be ridiculed as sissies if they expressed feeling sadness or pain or demonstrated other aspects of vulnerability. Males tend to get more “cool points” for behaviors such as picking fights or punching walls than for engaging in other types of self-harm such as cutting.

Whitlock et al. also discussed how LGBTQIA individuals are affected by self-injury. Those who identify as LGBTQIA self-injure more frequently than do their heterosexual counterparts. In particular, bisexual females were 6.2 times more likely to have engaged in self-injury at some point during their lifetime. These data showed that this subgroup is at the highest risk for NSSI out of the other populations studied in terms of gender and different types of sexual orientation. This is clearly a population at high risk that needs to be monitored.

I have found that individuals in this subgroup often self-injure because they feel split between what is expected of them and who they really are. They tend to carry a significant amount of self-blame for not meeting those expectations or feel frustrated for having what they believe to be disturbing thoughts. When their secret lives become consuming, they often turn to self-injury for “escape.”

Trauma and bullying victims are also at high risk for self-injury according to Laurence Claes and colleagues’ 2015 study, Bullying and victimization, depressive mood, and non-suicidal self-injury in adolescents: The moderating role of parental support,” published in the Journal of Child and Family Studies. Those who have experienced trauma can internalize the event, which causes emotions that are difficult to handle and makes them more susceptible to NSSI. Clients who frequently experience bullying or peer rejection also tend to self-injure more than their counterparts do. My past students who were victims of bullying or abuse often felt that they could not fight back; in other words, they did not externalize their behavior as a coping mechanism. This then led them to an internalizing coping mechanism, which resulted in self-injury.

Myths about self-injury

The following myths are inspired by a fact sheet on top misconceptions about self-injury produced by Saskya Caicedo and Janis Whitlock for the Cornell Research Program on Self-Injury and Recovery.

Self-injury is a suicide attempt or a failed suicide attempt. Research has shown that most people who self-injure do not have the intention to die by suicide. The main motivation for self-harm is to deal with emotional stress or pain. The category name of nonsuicidal self-injury in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders provides a sense of separation from suicidal intent. This category is also being used by other organizations and in research, thus creating a distinct line between self-injury and suicidal intent. The majority of my students who self-injure have expressed no interest in ending their lives; they were simply causing superficial injuries.

Self-injury is done to seek attention. Some individuals may use self-injury as a tool to seek attention, but it is important to realize that this action still represents a desperate cry for help. Why are they going to such drastic lengths to get attention? This is a question that we, as counselors, need to ask ourselves so that we can intervene accordingly. However, the majority of those who self-injure go to great effort to hide any evidence of cuts or scars. They tend to be secretive and have a difficult time discussing the underlying issues that plague them. Those who cut in secret demonstrate extreme emotional distress and need substantial help.

Anyone who self-injures is part of the Goth or emo subgroups. Research shows that self-injury is not limited to one specific group. Self-injury does not occur on the basis of gender, socioeconomic status, sexual orientation, social group, race, profession or other categories. It is true that some groups are more affected than others by self-injury (as seen in previous demographics), but no group is completely excluded.

Someone who self-injures can quit if they really want to stop. Many experts in this area indicate that self-injury has the qualities of an addiction. The act of self-injury causes endorphins and other neurochemicals to be released in the brain, which essentially gives the person a type of “high.” The chemicals eventually dissipate, and then a craving develops to experience that feeling again. This creates a cycle of addiction that makes it even harder to stop the behavior. Many individuals may need help and additional support to be able to stop self-injuring.

Although I have students who experiment with cutting and do it out of curiosity, there is a subgroup of students who chronically self-injure. They can’t seem to “kick the habit,” no matter how hard they try. Typically, this means that their underlying issues have yet to be resolved and that an adequate replacement coping mechanism needs to be put in place.

Someone who self-injures is a danger to others. Typically, those who self-injure are people who tend to internalize their emotional issues rather than externalize them. In other words, people who self-injure take their frustrations out on themselves rather than on others. This particular trait makes it highly unlikely that people who self-injure would harm someone other than themselves.

Why do people self-injure?

From my experience, there are a few main reasons that someone may self-injure. These do not, by any means, cover every possibility. In addition, some people may have multiple reasons that motivate their behavior to self-injure.

As a coping mechanism: Based on research findings, self-injury is a way to cope with emotional pain and distress that can stem from mental illness or trauma. These two issues typically involve internalizing behaviors, which is one of the factors in the personalities of those who self-injure. Those who self-injure lack healthy coping skills that allow them to function.

To feel or to numb: Especially in cases of depression, there can be physical symptoms such as numbness and emptiness. This disconnect with the body can cause individuals to self-injure for the sake of being able to feel something again.

On the opposite end of the spectrum, some people feel too much. This tends to occur in people who may have anxiety and are overwhelmed by emotions. Self-injury for these individuals is a form of distraction that places their focus on the injury rather than on the tidal wave of emotions engulfing them.

To self-punish: People who use self-injury for this reason tend to loathe themselves and to have extremely poor self-esteem. They often are perfectionists and will punish themselves for perceived academic, athletic or social failures. This is often where the high achievers are grouped: They expect nothing less than perfection from themselves, and they “pay for it” when they believe that they have fallen short.

Immediate interventions

The following are examples of immediate interventions that counselors can take with clients who engage in self-injury.

Screen for suicide. Although it has been established that the majority of self-injury cases do not involve suicidal intent, it is important in new cases to establish which category the action falls under: NSSI or preemptive attempt of suicide.

It is always a good idea to ask some screener questions such as “Have you thought about suicide?” and “Do you have a plan?” But avoid asking, “Do you think about hurting yourself?” It is obvious that the person is already hurting themselves, and if they answer that question affirmatively, then it is likely because they are engaging in NSSI versus trying to kill themselves. However, a misunderstanding about their answer could lead to a false positive of the person being suicidal. If the person does present as suicidal, then follow additional threat assessment guidelines.

Be aware of the need for medical attention. If the individual presents with fresh injuries, counselors should be alert to possible infections, the need for stitches or other medical issues that may arise. Often, people who self-injure cover up their cuts or injuries, and the trapped moisture can cause a bacterial yeast infection. With those who have created bruising, it is important to check for possible broken bones. This evaluation also creates an opportunity for counselors to explain the risk factors that accompany self-injury and how students or clients can protect themselves from medical crises.

Notify a family member or person of support. In these situations, it is necessary to inform the individual’s parent, spouse or person of support. Self-harm is a sign of serious emotional distress, and the family needs to be made aware of what is happening so that they can be on the alert. It is also wise to talk with the person about removing any objects they could use to harm themselves, such as knives, scissors, push pins, lighters and so on. When first speaking with the student or client, try to collect information about which instruments they favor in inflicting self-harm so that there is a better idea of what objects need to be removed. Working with significant people in the client’s life is key to ensuring the client’s safety.

Supportive interventions

The following are examples of supportive interventions that counselors can use with clients who engage in self-injury.

Identify triggers. One of the best strategies for helping students or clients who engage in NSSI is to identify their triggers. Does it involve perceived failure? Does it involve feeling awkward? Does it involve rejection by peers? Once the triggers are named, the next step is to work with the student or client to outline a plan for when these triggers arise. What alternative strategy can they use? What kind of self-talk will they employ? Do they need a break from the stressful activity? All of this needs to be planned and practiced.

Identify a network of trusted individuals. What I have learned on the basis of my students’ experiences is that part of the method of operation for those who self-injure is to isolate. When students or clients do try to stop engaging in self-injury, they will need some sort of outlet for dealing with all of their complex emotions. Working with these students or clients to come up with a group of people they can trust is crucial to their recovery.

Find appropriate replacement behaviors. Odds are, the person has been using self-injury as a coping mechanism for a long time, and in order to recover, they will need to learn healthy coping strategies. Many people who struggle with self-injury are often high-sensory seeking, particularly with tactile sensory input. Replacing self-injury with fidget items that provide tactile feedback (cotton balls, string, erasers, textured stress balls, etc.) may offer more successful replacement behaviors.

Other methods of expression, such as drawing or writing, can also be beneficial because they provide an outlet for the person’s anxieties. This makes it less likely that the person will bottle up their emotions as much.

Use cognitive behavioral techniques. Cognitive behavioral techniques include identifying cognitive distortions (“thinking errors” or “thinking traps”) and learning how to engage in positive self-talk. They involve the realization that when we are thinking negatively or getting stuck on an inaccurate idea, that may skew our perspective. Some examples include:

  • Mind reading: Thinking that we know what others are thinking about us
  • Ignoring the good: Paying more attention to things that are bad
  • Setting the bar too high: Expecting ourselves to be perfect
  • Blowing things up: Making a small thing into a big deal

Once the student or client gains awareness of their faulty thinking, they can replace it with positive self-talk. For example, for ignoring the good, a student might say, “In my paper, I had trouble with this section, but I did a good job with explaining my argument overall.” For further information, refer to the “Thinking Errors” worksheet at therapistaid.com.

Encourage self-compassion. Strategies that involve identifying clients’ strengths and talents can help them to better understand and embrace their positive aspects. Helping students find activities in which they can really shine and develop their strengths is especially beneficial.

Safe websites that offer support

It is important to be wary of online supports for individuals who engage in NSSI. I have often encountered so-called support groups online whose members showed graphic pictures of self-injury in a sense of one-upmanship. These sites are triggering and tend to encourage further self-injury.

Over the years, I have found the following sites to be both helpful and safe:

By using these strategies and resources, we can support our clients in developing new and positive coping skills. Together with their families and outside providers, we can make a difference in addressing NSSI.




Lauren Appel is a behavior specialist in a North Carolina school system with a background as a school counselor. Contact her at lauren.appel@caswell.k12.nc.us.


Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The ‘storm and stress’ of adolescence and young adulthood

By Laurie Meyers October 25, 2018

For much of human history, the idea of adolescence being a distinct life stage was nonexistent. True, in the Middle Ages, children were recognized not merely as “mini” adults but as distinct beings with different needs. However, the years from ages 13 to 19 were not considered part of childhood until the turn of the 19th century. Instead, the “teen years” were the time when one began to assume adult responsibilities such as making a living and starting a family.

During the late 1800s, changes in child labor laws and the push for universal education for those under the age of 16 began to influence society’s perspective on when adulthood began. G. Stanley Hall, the first president of the American Psychological Association (APA), is credited with the modern “discovery” of adolescence, defining it in a 1904 book as a new developmental stage — created by societal changes — in which children grow into adults. Hall described adolescence as a time of “storm and stress” and, unlike later researchers, ascribed this life stage as lasting from ages 14-24 (rather than today’s generally accepted range of 13-19).

Although adolescence is still considered to be synonymous with the teen years, Hall’s instinct to single out the early 20s as different from later “adult” years was prescient. In the past decade, neurological research has discovered that the brain does not fully mature until one’s mid-to-late 20s. This revelation has spurred many researchers, particularly in mental health fields, to call for a separate developmental stage that is generally referred to as “young” or “emerging” adulthood.

Adding more than a soupçon of complication to both the recognition of emerging adulthood and the established research on adolescence is the reality that being a teen or 20-something in the information age is, in many ways, significantly different — and arguably more difficult — than it was for previous generations.

Stressed and depressed

An abundance of research indicates that teens and young adults are experiencing increased levels of stress and depression. In recent years, APA’s annual “Stress in America” survey has gathered data only on adults. However, in the survey released in 2014, “Stress in America: Are Teens Adopting Adults’ Stress Habits?” young people ages 13-17 were also included.

Survey respondents reported that during the school year, they had a stress level of 5.8 on a 10-point scale. During the summer break, teens reported a slight decrease in stress levels — 4.6 on a 10-point scale. Furthermore, 31 percent of survey respondents said that their stress levels had increased over the past year. In response to their high levels of stress, 40 percent of respondents reported feeling irritable or angry, 36 percent reported feeling nervous or anxious, 36 percent reported feeling fatigued or tired, and 31 percent reported feeling overwhelmed.

Depression is another significant concern among adolescents. According to the National Institute of Mental Health, in 2016 (the most recent year for which statistics are available), an estimated 3.1 million adolescents ages 12-17 experienced at least one major depressive episode. That number represented 12.8 percent of the U.S. population in that age bracket.

Although most mental health surveys do not specifically target “young” or developing adults, data are available relating to college students. Among the more than 31,000 college students who completed the 2017 American College Health Association National College Health Assessment, 39.3 percent reported being so depressed that they found it hard to function at some point during the previous 12 months. Anxiety levels among respondents were even higher: 60.9 percent reported feeling overwhelming anxiety at some point during the prior year.

The high levels of anxiety and depression indicated in these studies are part of a national pattern of significantly increasing distress. A national poll published in May by the American Psychiatric Association noted a sharp increase in American anxiety levels over the past year. On a scale of 0-100, this year’s “national anxiety score” was a 51 — a five-point jump since 2017. A study published in the June 2018 issue of the journal Psychological Medicine found that rates of depression rose across all age brackets of Americans for those 12 and over from 2005 to 2015. Most significantly, among those ages 12-17, depression rates increased from 8.7 percent in 2005 to 12.7 percent in 2015.

Under pressure

Some researchers are eager to blame technology — particularly social media — for the increase of depression and anxiety among teenagers and young adults. The reality is more complex and involves myriad factors.

It is undeniable that some people do find their lives lacking when compared with what they see on social media. Carefully curated Facebook feeds can suggest to them that their friends are happier and more successful than they are. Celebrity photos on Instagram — most of which are professionally produced and heavily filtered — can encourage unrealistic expectations about body image and personal appearance. However, when one considers the role that social media plays in the quest for perfection, it may be something of a chicken-and-egg scenario.

A 2017 study on perfectionism that appeared in the journal Psychological Bulletin found that beginning in the 1980s, a culture of “competitive individualism” in the United States, Canada and the United Kingdom steadily increased the quest for personal perfection. So, is what we see on social media pushing us toward unattainable standards of perfection, or is it a reflection of the pressure we put on ourselves? At this point in time, we may be caught in a reinforcing loop. The study found that current generations not only feel intense societal pressure to be perfect but also expect perfection from themselves and others. The study’s authors also believe that this rise in perfectionism may be linked to an increase in myriad psychological problems.

Today’s teenagers and young adults are unquestionably subject to high expectations and demands. Licensed mental health counselor David Flack, who has worked with adolescents and young adults for 20 years, says he has seen a significant increase in anxiety related to academic performance among his clients.

“It is not uncommon for teens I meet with to have three, four or even more hours of homework most days,” he says. This reality creates significant pressure and is particularly stressful for students who are predisposed to anxiety. Flack, a member of the American Counseling Association, also believes that such heavy academic workloads are interfering with important social and developmental processes because many teenagers may be spending more time doing homework than socializing and engaging in extracurricular or other age-appropriate activities.

Licensed professional counselor (LPC) Sean Roberts, an ACA member who specializes in working with young adults, says he has witnessed a precipitous increase in anxiety among clients. He thinks this is strongly, though not solely, linked to teenagers and young adults feeling increased pressure to succeed.

Not coincidentally, the anxiety they experience makes it only more difficult for them to achieve. “Anxiety has a neurological effect,” explains ACA member Amy Gaesser, an assistant professor of counselor education at the State University of New York at Brockport whose research focuses on the social and emotional well-being of students in school. “The survival part of the brain activates and shuts off or interferes with the parts of the brain that help us think clearly.”

This can have a significant effect on academic performance, says Gaesser, a certified school counselor in New York who gives presentations and offers private consultations with parents. For example, some students can study extensively and be fully prepared for a test, but because of their anxiety, can have trouble accessing that information while taking the test. Anxiety can also interfere with the ability to take in and synthesize information, Gaesser says. Students become frustrated with their seeming inability to “get it,” which affects their feelings of self-efficacy and can even make them question their level of intelligence. Once a pattern of academic difficulty tied to anxiety is established, the problem can become self-perpetuating.

Disrupting the cycle is vital, says Gaesser, who recommends the emotional freedom technique (EFT) as an effective method of interrupting the stress response and downregulating the brain. In EFT, participants respond to stressful thoughts or situations by visualizing an alternative outcome while taking their hands and tapping acupuncture points on the body that have been linked to stress reduction. Students can go through the whole sequence of body points or just use the areas they find work best for them, she says.

Gaesser also recommends the “4-7-8” breathing method as a quick way to interrupt the stress response. This involves breathing in for four seconds, holding the breath for seven seconds and then breathing out for eight seconds. Students can practice this method themselves, but Gaesser thinks that teachers should also use it in their classrooms as a way to begin class.

Peter Allen, an LPC based in Oregon who specializes in counseling young adults and adolescents, used to work with teenagers in a wilderness therapy setting. Most of his clients were struggling with a variety of issues, including substance abuse, conduct problems (although not usually at the conduct disorder level) and mood disorders, principally depression and anxiety. In most cases, Allen says, the core elements of the wilderness setting were effective in helping these clients address their various presenting issues.

In part, he believes that’s because the pressures of school, family and social life were stripped away, leaving these teenage clients to focus on the basics, such as securing food and shelter. Surviving in the wilderness also required working together and building a community, which helped teach clients new communication skills. Participants also got daily exercise, ate healthy meals and were required to follow a regular sleep schedule, all of which had a calming and stabilizing effect. “Once diet, sleep and exercise have been regulated, about half of the problems disappear right away,” Allen says.

Many wilderness therapy clients also benefit from what Allen calls “expanding the size of their world. … If you are a 15-year-old kid and doing bad at school, arguing with your parents, your world is tiny.” The wilderness program not only provided literal wide-open spaces, but also introduced clients to people from different places and adults who didn’t have the same expectations as the teenagers’ parents or teachers did.

The wilderness can also serve as a mirror for clients, says Roberts, who has also worked in wilderness therapy, or, as he says it is becoming more commonly known, outdoor behavioral health care. For instance, when clients who struggle with executive function and organization encounter bad weather for which they are not prepared, the experience can be a vivid demonstration of the importance of working on those problem areas. Another example: Someone who is struggling with distress tolerance will need to get used to having to build a fire after hiking all day.

Information overload?

Although none of the counselors interviewed for this article view social media or technology as inherently negative, they agree that living in the information age is complicated. The current generation of teens and young adults is awash in an unprecedented flood of information, asserts Roberts, clinical director at Cascade Crest Transitions, a program that provides support to young adults struggling to launch their independence by attending college or obtaining a job. He maintains that this technological bombardment not only is difficult to assimilate but also can encourage the tendency to “get stuck” in one’s own head.

Allen adds that in the age of the internet, children and adolescents are exposed to a lot of information and knowledge at an earlier age than previous generations were. In certain cases, it is information that they may not have the maturity to handle. For example, most children and adolescents who grew up in the latter half of the 20th century had to somehow get their hands on a copy of Playboy or another adult magazine to satisfy their sexual curiosity. Today’s children and teens are exposed online to myriad genres of easy-to-access pornography, which not only present unrealistic ideals of sexuality but also can include disturbing practices such as bestiality and pedophilia. Children and young adolescents today are also more likely to be exposed to media coverage of frightening or horrific events before they have the ability to contextualize all that they are taking in, Allen says. He believes this early exposure is contributing to a kind of “nonspecific existential dread” that he says he commonly sees in his clients.

Roberts says that technology offers many positive benefits, but it also sometimes provides adolescents and young adults with a means to avoid their problems. He stresses the need for counselors to learn more about the draw of technology so that they can help clients evaluate whether they are using it in positive or negative ways. Roberts gives gaming as an example. For those who know little about it, gaming may seem like an excuse to “do nothing.” In reality, he says, it is a legitimate hobby that can provide enjoyment, stress release and even a sense of community while boosting problem-solving skills. However, like any other activity, when gaming gets in the way of schoolwork, chores or getting out of the house, it becomes a problem to be addressed, he says.

Another complicated aspect of online life is social media. For all the potential benefits, social media feeds have made it so that virtually no part of life is private anymore, Allen says. Many adolescents may not fully understand that by making everything public, the internet is, in essence, “forever” or grasp the potential ramifications of that reality, he says. In addition, he notes, social media feeds can encourage social contagion.

ACA member Amanda LaGuardia, a former private practitioner whose research focuses on self-harm, agrees. Much of the social media content targeted to young girls is focused on body image, says LaGuardia, a licensed professional counselor supervisor in Texas and a licensed professional clinical counselor supervisor in Ohio. Many of her former clients talked about the images they saw on Instagram, such as already-thin celebrities discussing “thigh gap” (as part of a supposedly “perfect” body, women and girls must have thighs that don’t touch each other) and other unrealistic physical standards. Such posts are usually popular, garnering a large number of likes and admiring comments, which gives girls the impression that this is what their bodies should look like, she says.

However, such standards are unrealistic for most females and are simply unachievable for girls with developing bodies, continues LaGuardia, an assistant professor at the University of Cincinnati. Regardless, these images are presented as the feminine ideal, presuming to highlight all of the elements that will make women attractive to men. At the same time, girls are often subject to sexual harassment at school and too often told by those in authority “that’s just how boys are” (boys will be boys) and that girls just need to find a way to deal with it, she says.

All of these messages about how girls should look and act and what they should accept come at a time when they are already struggling to figure out who they are. It is overwhelming, and self-injury is becoming a more common way to cope with the distress. Self-harm used to be most common in the eating disorder population, but according to LaGuardia, social media has introduced it to a wider audience. It isn’t necessarily that self-injury is presented as a positive behavior online. Most people who talk about it on social media are seeking support, she says. However, the widespread nature of the discussion has created social contagion.

The best thing counselors can do to help is listen and affirm, LaGuardia emphasizes. When adolescents talk about their experiences, some counselors focus on helping them feel better about themselves, but that is not what they need most, she asserts. Instead, adolescents need to express what they are going through and to process their confusion verbally. Counselors should respond, she suggests, by saying things such as, “That sounds really difficult” and “I’m here and I’m listening.”

“So many of the messages they [adolescents] are receiving are controlling,” LaGuardia explains. “They need to feel in control.”

As these clients become more comfortable, they will begin to talk about how they are coping with their turmoil. LaGuardia explains that these clients view self-injury as a means of surviving what they are currently experiencing, not a solution. “I ask clients, ‘Is this something you see working for you for the rest of your life?’ I’ve never had anyone say yes.”

Usually, LaGuardia notes, clients will say that they hope not to engage in self-harm forever, but at the current time, they don’t know what else to do. At that point, counselors can ask whether this coping method is something the client is ready to change. LaGuardia says the first step is finding out what the client needs help coping with and then exploring ways that will allow the client to cope without self-harm.

The most common underlying problem for clients who self-harm is conflict with a parent or sibling, LaGuardia says. In such cases, she works with the whole family on communication skills. She starts with the adolescent clients, teaching them how to express their needs without self-injury. She asks the adolescents to think about their most stressful conflicts and what they would like their parents to know. Then, through role-play, LaGuardia helps these clients practice asking for what they need.

Often, LaGuardia will also bring in the parents and have the adolescent express the source of conflict. As the parents and adolescent talk, things can get heated, so LaGuardia is there to help redirect the conversation. She also tries to educate parents about what adolescents need, which includes being treated as independent young adults and given space to grow, while at the same time knowing that their parents are always there to listen to them regardless of
the circumstances.

Adult transitions

Allen is the program director at College Excel, a residential, coaching-based college support program. The program’s clients are typically young adults who are coming out of high school and looking for extra support to succeed in college or those who previously attended college but dropped out because of a mental health issue or learning disability.

Many of the students have some level of anxiety and depression and often struggle with executive function deficits. College Excel provides the students with mental health support and coaching on life and study habits. Allen says he tries to run the program through the lens of good mental health practices. Calling on his background in wilderness therapy, he also encourages students to eat well, follow a consistent sleep schedule and get regular exercise. College Excel staff do not live on-site, but the program does provide students with housing, which helps them establish a sense of community and support — elements that are common among those who successfully adjust to college life, Allen points out.

Allen says that many of the program’s clients struggle with attention-deficit disorder and organization. College Excel staff teach students basic organizational skills such as using their attention strategically. For example, with students who struggle with memory and retaining information, Google Calendar can be a particularly useful tool. It can tell students where they need to be at any given moment, freeing up their attention and memory for other tasks.

Allen also talks with students about the importance of a clean workspace and provides them with practical tips on organization. For example, he says, students who constantly misplace things can save time and frustration by designating a space for pens, papers and other basics so that they will always know where to find them.

Students also work on developing good study habits. For example, rather than growing frustrated with their struggles to focus on what they’re reading for long periods of time, clients learn to study in 15- to 20-minute chunks, with five-minute breaks in between.

Roberts’ program is geared toward young adults who are coming from inpatient treatment and are ready to enter college or find a job. In addition to receiving ongoing mental health treatment, these clients take classes that focus on interpersonal skills, stress regulation, goal setting, time management and money management. They are also encouraged to exercise, and all students are matched with a case manager who helps them focus on sleep hygiene, peer interaction, health and nutrition, and, in some cases, dating.

Clients are required to attend one individual and one group counseling session per week. Counselors are also on-site five days a week, which allows them to give feedback outside of sessions. For example, a counselor might say to a student, “You say that you want to socialize, but you’re constantly retreating to your room or on the phone.” This opens up a discussion about why the student isn’t following through on counseling goals and allows the counselor and client to work on solutions together, Roberts says.

The students are usually enrolled in college or working when they start Roberts’ program. The coaching and classes take place around the students’ schedules, and staff members are available to help clients through whatever challenges they are facing in school or at work. Clients typically remain in the program about nine to 12 months. During the last six months, they move out of program housing and into their own apartments or college dorms.

Allen closes by noting that today’s adolescents and young adults — the oft-discussed millennials — are very much aware that older generations generally view them in a negative light. He believes this widespread maligning carries a psychic weight for this generation and can contribute to limiting their self-efficacy and sense of options.

Because this negative image of adolescents and young adults is so prevalent, Allen believes that even counselors may fall prey to it. “You can’t hold them in contempt and do good work,” he emphasizes. “The best thing we could be doing for them is stoking the fire of creativity.”




Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books and DVDs (counseling.org/publications/bookstore)

  • Youth at Risk, sixth edition, edited by David Capuzzi and Douglas R. Gross
  • A Contemporary Approach to Substance Use Disorders, second edition, by Ford Brooks and Bill McHenry
  • Active Interventions for Kids and Teens, by Jeffrey S. Ashby, Terry Kottman and Don DeGraaf
  • Suicide Assessment and Prevention, DVD, presented by John S. Westefeld

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Suicide Prevention
  • Substance Use Disorders and Addiction
  • LGBTQ Resources


  • “Depression/Bipolar” with Carmen S. Gill (CPA22120)
  • “Trauma/OCD/Anxiety” with Victoria E. Kress (CPA22118)
  • “Substance Abuse/Disruptive Impulse Control/Conduct Disorder” with Shannon Karl (CPA22116)
  • “Counseling Students Who Have Experienced Trauma: Practical Recommendations at the Elementary, Secondary and College Levels” with Richard Joseph Behun, Julie A. Cerrito and Eric W. Owens (CPA24339)




Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

’13 Reasons Why’: Strengths, challenges and recommendations

By Laura Shannonhouse, Julia L. Whisenhunt, Dennis Lin and Michael Porter September 4, 2017

The Netflix series 13 Reasons Why has launched a national discussion regarding teen suicide, motivating a webinar response from professional organizations about how to shape the dialogue, dozens of editorials and millions of cautionary letters home from schools to parents across the country.

The series, based on a novel, is narrated by high school student Hannah Baker, who made a series of cassette tapes to be passed to 13 individuals she argues contributed to her reasons for dying. Her story is seen through the eyes of a peer, Clay, who listens to the tapes. He comes to understand Hannah’s perspectives about those people and events she claims motivated her suicide, which include Clay’s own (in)actions.

The series has been critically acclaimed for the acting and commended for addressing challenging topics, such as bullying/cyberbullying, sexual assault and teen suicide. However, school administrations, school counseling associations, suicide prevention organizations and counseling/psychology associations such as the American Foundation for Suicide Prevention (AFSP), the Suicide Prevention Resource Center (SPRC), the American School Counselor Association (ASCA) and the National Association of School Psychologists (NASP) have advised caution because of the graphic nature, revenge fantasies and potential contagion effect. This article highlights strengths and major challenges of the series. It also provides recommendations that have been underrepresented, though not absent, in the discussion.



1) Raising awareness that suicide is a real problem.

According to the Centers for Disease Control and Prevention (CDC), suicide is a major public health issue. The most recent  statistics available note that among high school students, 17 percent have seriously considered suicide, while 8 percent have attempted suicide within the past 12 months. We know that for every suicide, there are many survivors, including the family and friends of the person and those who have experienced psychological, physical and social distress after exposure to a suicide.” The most commonly cited statistic is that each suicide directly affects six people; however, more recent research argues there are between 45 and 80 survivors per suicide.

In 2015, there were more than 44,000 reported suicide deaths, including 5,191 deaths by suicide among those ages 15 to 24. However, this statistic includes only those that were reported. Although there is no consensus on the rate of under-reporting due to stigma or ambiguous cause of death, the best analysis suggests that for each completed youth suicide, there are 100-200 times as many nonfatal suicide actions.

Combining CDC data with our current understanding of rates of suicidal ideation in youth, in this moment there are close to 15 million people in the U.S. who think of suicide in any given year. Suicide is a very real public health issue; when it is ignored, stigmatized or minimized, we as a community are missing the chance to prevent it.

2) Even professional counselors may not be ready to respond to a suicidal situation.

Because counselors often receive referrals of clients who are suicidal, counselors’ competency in identifying and intervening with those at risk is crucially important. However, the overtaxed counselor in 13 Reasons Why, Mr. Porter, is underprepared to face a suicidal student coping with complex trauma. Although he did not act in the scope of best practice, his failings are unfortunately not unusual among counselors, despite decades of advocacy for increased suicide assessment trainings in counselor education.

Mr. Porter missed several suicidal statements (e.g., “I need everything to stop”), made assumptions about contributing events and was uncomfortable talking about suicide (and other issues). We may easily judge Mr. Porter’s mistakes, but as counselors, we should take this opportunity to reflect and ask ourselves if we are ready to respond to a student at risk of suicide. The research is equivocal.

3) Suicide is complex and individual.

Although 13 Reasons Why portrays some known “red flags” that can indicate suicidal intent, the factors that contribute to individual suicides vary. Stressors that may influence one person’s decision to die by suicide may not have the same effect on others. For instance, we know that not all people who are depressed die by suicide (research shows the rate is from 2-15 percent) and that not all people who complete suicide are depressed. There is a variety of prevention programming regarding common warning signs. However, there is no perfect amalgam of warning signs or demographics (e.g., risk for transgender persons) that helps us differentiate who will decide to die by suicide. We need to go beyond just learning warning signs in order to help.

Livingworks, a suicide intervention training organization, focuses on three elements when assessing warning signs and risk factors. First, we must look for the meaning behind stressful events. For instance, in 13 Reasons Why, being listed “Best Ass” was highly distressing to Hannah because she felt objectified and was concerned people would misperceive her to be easy. However, another student, Angela “Best Lips” Romero, was flattered by such attention. The meaning behind the stressful event is more important than the stressful event itself.

Second, we need to know that warning signs can be, and often are, expressions of pain. When Hannah pushed Clay away, he recognized that something was wrong but did not see that her rejection was an indication of emotional pain. Third, we must trust our intuition. One peer recognizes Hannah’s poem as a cry for help but does not offer assistance. We need to pay attention to our gut feelings and act on them to take care of each other.

13 Reasons Why provides an opportunity to see Hannah’s experience of several traumatic events (cyberbullying, being stalked, public objectification, losing money, feeling responsible for a person’s death, witnessing rape and being raped) and does a good job of depicting the pain, shame and isolation she experiences as a result. The viewer has an opportunity to consider Hannah’s subjective experience and understand how the cumulative effect of these “reasons why” motivates her to suicide.

One model to help contextualize suicidality is the interpersonal-psychological theory of suicidal behavior developed by psychologist Thomas Joiner. Joiner states that the highest risk occurs when one feels like a burden to others, feels alienated or lacks belongingness and, crucially, has overcome the natural human inclination toward self-preservation. This model posits that suicide is a process — one gradually builds tolerance to the idea through self-injurious thoughts or behaviors (although each person’s path is unique). There are multiple points on that path at which others can intervene. The 13 Reasons Why series emphasizes those missed opportunities. As in Hannah’s case, every day there are suicides that happen as a result of those missed opportunities.

4) The central message is a positive one.

In the last episode, Clay says to Mr. Porter, “It has to get better, the way we treat each other and look out for each other.” Instead of feeling guilty or turning away, we can task ourselves with being more supportive community members.

All too often, we operate from a place of fear, which is understandable considering that schools have a legal duty to protect students from self-harm, and lawsuits are a potential reality (as shown in 13 Reasons Why). However, when systems or individual responders act out of fear, it focuses the interaction away from the needs of the person at risk. Even well-intentioned modern practices of “suicide gatekeeping” have substituted swift (and protocol-driven) identification and referral for the direct supportive intervention by community members proposed by John Snyder in 1971. Clay’s words echo those from Snyder half a century ago, when he said that most “who attempt suicide are victims of breakdowns in community channels for help.”

Although Mr. Porter clearly failed to proper identify Hannah’s suicidal ideation, perhaps even more troubling was his failure to hear her story and understand the factors behind her decision to die by suicide. Listening and demonstrating empathy to someone who is struggling was demonstrated to reduce suicidal ideation on calls to the National Suicide Prevention Hotline. Talking about suicide can help the person at risk to no longer focus on the past or feel alone and, instead, shift to the present moment, where the person can feel understood and cared for. If those in Hannah’s community who were witness to her emotional pain had actively engaged her and listened, it may have reduced her isolation and lessened her self-perception as a burden. This may even have prevented Hannah’s death.

Research indicates that our personal beliefs about suicide influence our responder behaviors. Therefore, gaining awareness of our beliefs and how our ability to intervene is affected by them is vital. Regardless of whether we can stop a suicide, we can control how prepared we are to try. We can make sure that our systems (in schools and elsewhere) are places where it is easy for someone to receive help.

After working through Hannah’s tapes, Clay now believes that we are, in a way, our brother’s keepers. Community-level response by direct intervention is a central theme in my (Laura Shannonhouse) research. It involves equipping “natural helpers” (e.g., teachers, bus drivers, resources officers, school counselors/psychologists) with the skills needed to perform a life-assisting suicide intervention at the moment it is needed most.

The producers and cast of 13 Reasons Why have underscored their desire for this series to start a conversation. Although that has certainly been accomplished, we hope the dialogue focuses more on how we can “look out for one another” and foster communities less at risk for suicide.



1) Graphic nature and contagion

Viewers of 13 Reasons Why watch two rape scenes and Hannah’s suicide, which is shown in detail. Nic Sheff, one of the writers of the series, stated that the scene of Hannah’s suicide was intended “to dispel the myth of the quiet drifting off.” Some crisis texts suggest that we “deromanticize” suicide by helping our clients understand the unintended effects of trying to die by suicide, such as surviving but becoming disabled or alienating friends and family. Therefore, an argument could be made that a graphic, painful portrayal of suicide is warranted.

However, research does suggest that suicide portrayals can contribute to contagion by triggering suicidal behaviors in people — particularly youth — who are experiencing high levels of emotional distress. In fact, SPRC and AFSP have made recommendations for best practices in prevention of suicide contagion. A discussion of post-suicide intervention to prevent contagion is beyond the scope of this article, but as an example, the locker memorial portrayed throughout the series is against standard guidance (it should not last for weeks, as shown). Furthermore, when considering how media reaction to the series has often included sensational headlines, it is helpful to review these recommendations for reporting on suicide.

2) Survivor’s guilt and revenge fantasies

By assigning “reasons why,” the series sends a message that Hannah’s death is caused by other people’s actions. When Clay openly questions, “Did I kill Hannah Baker?” his friend Tony answers dramatically, “Yes, we all killed Hannah Baker.”

Although we suggested earlier that we all have a responsibility to create communities that help prevent suicide, Tony’s level of direct attribution can be counterproductive. Hannah experienced multiple losses, traumas and stressors caused by others, both intentionally and unintentionally. Placing responsibility for her death on those individuals instead of on Hannah’s action can exacerbate survivors’ guilt. Those viewers who have lost a friend, loved one or acquaintance to suicide may feel even more strongly after viewing the series that “It is my fault.”

These feelings are associated with lower functioning in comparison with survivors of accidents. Although undeserved, survivor’s guilt is a real phenomenon, and considerable research shows that even counselors who experience the death of a client by suicide can experience shame/embarrassment and emotional distress.

Whereas Clay may feel guilt for his part in Hannah’s story, the tapes could implicate others in criminal or negligent behavior, perhaps giving Hannah posthumous revenge. Some viewers who may have struggled with suicidal ideation themselves could get the message that if they take their lives, they can get revenge on those who have hurt them. This is an additional reason that schools across the nation and professional helping organizations have felt the need to do damage control for 13 Reasons Why.



1) Parents need to not just talk but watch, listen and connect.

Some school counselors argue that it’s harmful for children and teens to watch the series on their own without the support of a parent or trusted adult because the series depicts a graphic and romanticized portrayal of a teenager in crisis and does not identify competent resources capable of helping her. Accordingly, many experts encourage parents to talk to their children about the series. In addition to using talking points, we recommend that parents listen deeply and without judgment to what their children say. When people feel genuinely heard, they are more likely to talk about their true thoughts and feelings.

To accomplish this goal, parents can use active listening skills, such as open-ended questions, reflections of feeling, paraphrasing and encouragement. Also, we recommend that parents watch the series and risk being human — risk being impacted by the series and empathizing with their child. The construct of empathy is powerful, particularly if it is sincere. For a three-minute visual summary, consider watching Brene Brown on empathy. In our counseling skills courses, we often talk about “getting in the well of despair” and genuinely connecting with others. We know that talking about suicide paradoxically provides a significant buffer to suicidal action.

2) We need more than prevention programming in schools.

We know from a well-regarded U.S. Air Force study that we need suicide programing at all three levels: prevention, intervention and post-intervention. Many suicide prevention programs have been implemented in the school context, but there is mixed evidence of their effectiveness. From our clinical experience in crisis response, our scholarship and our history with training a specific model of suicide intervention, we need to acknowledge that we are biased about what types of programming should be implemented and when is the right time to implement. We feel that an appropriate first step for a school system is to implement basic screeners and gatekeeper trainings such as Signs of Suicide or Sources of Strength.

However, suicide prevention should not end with identification for referral. Optimally, the process continues by assessing level of risk, identifying reasons for dying and reasons for living, discussing alternatives to dying, enlisting the support of trusted loved ones and limiting access to lethal means or securing the person’s environment. Because youth who struggle with thoughts of suicide often seek out the support of those they trust rather than professional mental health providers, those teachers, coaches and others with open hearts and doors are the most effective gatekeepers for a system. Their nondirection and empathy are useful pedagogical qualities and vital to effective suicide intervention.

We endorse models that empower those “natural helpers” to provide a potentially life-saving intervention for students who are in suicidal distress. Although this may be augmented with the support and follow-up of a trained mental health provider, gatekeepers can implement the steps listed above.

3) Be intentional about identifying caregivers and shifting school culture.

My (Shannonhouse) research involves partnering with school districts and superintendents (in Maine and Georgia) to identify “natural helpers” and equip them with the skills to perform a life-assisting intervention in the moment (i.e., Applied Suicide Intervention Skills Training, or ASIST). These natural helpers are often teachers, resource officers, coaches, administrative staff, bus drivers and other people who are likely to be confidants to students who experience distress. Measuring suicide intervention skills and responder attitudes is easy for an academic. Identifying those school personnel in the trenches who would be first responders is more difficult — it requires the total involvement of administrators. Furthermore, such an approach requires schools to commit to a student-centered response model.

ASIST is relationship-driven and aligned with the values of the helping professions. It meets the needs of students who are at risk by focusing on responding to those immediate needs rather than referring the student (which can lead to further isolation and an increased sense of burdensomeness). Although the student is often referred for more long-term counseling, ASIST provides the student with a six-step intervention at the moment it is most needed and can be performed by anyone over age 18. Having natural helpers trained in ASIST or a similar protocol can dramatically increase a school’s responsiveness and effectiveness to help students in distress.

4) Use an intervention model backed by research.

ASIST is a 14-hour, two-day, internationally recognized and evidence-based model that has been adopted by multiple states and the U.S. Army. It has also been recognized by the CDC and used in crisis centers nationwide. Caregivers trained in ASIST consistently report feeling more ready, willing and able to intervene with a person at risk of suicide.

The program has been evaluated in a variety of settings (click to download), with pretest to post-test improvement noted in trainees’ comfort level at intervention and in their demonstrated intervention skills in response to simulated scenarios. Although outcome research is rare, research compared ASIST-trained counselors with those trained in other models through a double-blind, randomly controlled study of more than 1,500 calls to the National Suicide Prevention Lifeline. Those trained in ASIST more often demonstrated particular behaviors such as exploring invitations, exploring reasons for living, recognizing ambivalence about dying and identifying informal support contacts. Those trained in ASIST also elicited longer calls.

We found that ASIST can be applied to both university and K-12 settings. Our work measured increased suicide intervention skills and beneficial responder attitudes, which have been maintained over time. We have trained more than 500 people in ASIST and have received multiple reports of teachers disarming fully formed suicide plans with their new skills. More recently, we have conducted behavioral observations of ASIST responder behavior and have begun evaluating outcomes of students who have received ASIST intervention. Initial results have been promising, including better coping and commitment to follow-up and decreased lethality.



Although 13 Reasons Why gives us pause for its poor portrayal of effective suicide intervention, we feel that the series raises awareness and, at its core, advocates a community-level response to suicide prevention. This message to “look out for each other” is aligned with more intervention-oriented gatekeeping. We have explored the impact of one such model, ASIST, in several educational settings and found that it improves responder behavior. Furthermore, this approach comes with a mindset that systems can harness their strengths (i.e., natural helpers) to focus on responding to and intervening with the student rather than simply identifying and referring the student to the system.




Please contact me (Laura Shannonhouse) should you have any questions about our research.



Laura Shannonhouse is an assistant professor in the Counseling and Psychological Services Department at Georgia State University. Her research interests focus on crisis intervention and disaster response, particularly involving social justice issues in this context. Currently, she is conducting community-based research in K-12 schools (suicide first aid) to prevent youth suicide and with disaster-impacted populations in fostering meaning-making through one’s faith tradition (spiritual first aid).


Julia L. Whisenhunt is an associate professor of counselor education and college student affairs at the University of West Georgia. She specializes in the areas of self-injury, suicide prevention and creative counseling. She is particularly interested in the relationship between self-injury and suicide and ways that mental health professionals can apply this knowledge to clinical intervention.


Dennis Lin is an assistant professor at New Jersey City University, with areas of expertise in play therapy, child/adolescent counseling and assessment, suicide prevention/intervention, quantitative research and meta-analysis. He is also a certified master trainer of Applied Suicide Intervention Skills Training (ASIST).




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.