This is a guide to peer support. I’m not a mental health professional and this is not medical or legal advice.

If you’re not sure what to do to help someone who’s engaging in self harm, read this before you panic.

First, is the person you’re concerned about in imminent danger of death or serious injury? Do they need immediate medical attention for their safety? If so, help them seek medical attention now. If not, it’s important to respect their right to bodily autonomy and support them in the ways they’re ready to accept from you.

It can be frightening and confusing to learn that someone you care about is intentionally harming themselves. While behaviors like cutting might seem perverse on the surface, self harm is quite common and is a logical and effective way for people to cope with powerful emotions and difficult experiences.

An introduction to self harm

While some people who harm themselves also want to end their lives, not everyone does. In fact, most people who engage in self harm behaviors aren’t trying to end their lives. This article focuses on non-suicidal self-injury (NSSI) and how to support someone who is not experiencing thoughts of suicide.

Self harm might be a cry for help, but many more people engage in acts of self harm in secret. Self harm most commonly a private way of self soothing:

They have no faith in any possibility of turning towards someone else for help. They are fundamentally alone. They only have experience of directing anger and sorrow in on themselves. They are taking their pain out on the only character they can reach. [On Skin Picking from The School of Life]

Common self harm behaviors include:

• cutting,
• puncturing,
• burning,
• scratching,
• pinching,
• picking at skin,
• biting oneself,
• head banging,
• hitting or punching oneself,
• pulling or removing ones own hair, and
• cutting off circulation to fingers or toes.

Self harm isn’t the inability to cope, it’s a highly effective but problematic way of coping. People may use self harm behaviors a few times or they may engage in forms of self harm over the course of decades without causing themselves serious injury.

People who engage in forms of self harm often feel shame about their behavior. Accepting them as they are, validating their feelings, acknowledging their strengths, and seeking to understand their experience is key to supporting someone who is using self harm to cope.

Why do people harm themselves?

People harm themselves for a lot of different reasons. In order to move past whatever alarm or disgust you may be experiencing, it’s helpful to acknowledge that self harm is a logical and effective response to their emotional pain. Self harm is such a popular coping mechanism because it calms people in a number of different ways, making it effective for all sorts of situations.

Self harm is such an effective coping mechanism because it allows people to:

• Focus on the physical sensation of pain to drown out their emotional pain
• Feel like they’re in control
• Release tension or anger
• Feel something when they feel emotionally numb
• Demonstrate the emotional pain they’re in by causing physical injury
• Punish themselves for something they feel they’re doing wrong
• Express their emotions

The person you’re concerned about might relate to one or more of these common reasons — or they may have a totally different reason.

Helping someone replace a problematic coping method for another requires that you be able to understand what they need and guide them through the process of finding another way to meet that need. The only way to find out the need(s) that self harm meets is to listen to them without judgment and make sure you truly understand.

I’ll provide you with more information on each common reason that self harm is so helpful, along with alternative coping methods that people who self harm have found useful. However, it’s critical that you understand that this is not your problem to fix. Telling someone what they should do to feel better or telling them how they should feel makes it seem like you’re dismissing their experience and trying to control them.

The best way to help someone is to make them feel understood and accepted for who they are, even if they choose to continue using self harm as a coping method.

Putting intentional harm into context

There are examples of self harm that are considered acceptable and appropriate, both today and throughout history. The line between appropriate and inappropriate types of self harm has shifted along with our culture.

Further, some schools of psychology believe all humans have an instinct to cause themselves harm. In the 1930s, Karl Menninger used Freudian theories to popularize the belief that people who injured themselves accidentally were exercising unconscious desires to harm themselves.

History is full of examples of self harm carried out as part of cultural and religious rituals. Christian history is rife with saints and devoted followers engaging in self-flagellation. Engaging in the mortification of the flesh is believed to purify one from their sinful nature. The Catholic Church no longer encourages self harm as a show of devotion, but that’s a modern interpretation of doctrine.

Today, self injury is seen as a culturally appropriate way, or at least a common way, of handling specific situations. Stories abound of people outwitting lie detectors by injuring themselves during the test, by puncturing their foot with tack in their shoe or biting their tongue. Young men have caused themselves injuries drastic enough to render them unfit for military service to avoid the draft and redeployment. Soldiers and people engaging in extreme sports put themselves in situations where they are all but certain to become injured.

Self harm is sometimes understood to be a normal, if troubling, part of a developmental phase. Young children commonly bang their head on the floor or hold their breath in order to demonstrate the strength of their distress. It’s seen as normal for young men to punch a wall, even when it breaks their hand in the process. Young men may drink to the point of putting themselves in physical danger, an activity sometimes paired with picking fights or driving drunk. Fraternity hazing rituals may involve harming oneself or allowing oneself to be harmed by others.

While most of us would say we avoid pain whenever possible life is full of situations where we cause ourselves physical pain. We are told “no pain, no gain” in working out and people often frame exercise as penance for overindulgence. Women undergo waxing and electrolysis to remove hair that is deemed unacceptable for women to have and use dangerous chemicals to change the texture of their hair. Healthy people undergo invasive and painful medical testing as a preventative measure. We eat foods so spicy that they lead to swelling of the mouth and lips, blisters, and pain. Family caregivers sometimes tell me how they are delaying their own treatment for cancer and other critical illnesses because they are too busy caring for others.

Even more commonly, minor self harm is used by people who need to maintain an air of calm when they are experiencing emotional distress:

She has a trick when she thinks she is about to cry: “I’ll dig my nails into my hand,” she said. “I’ll do something to stop the tears, because if I fall apart then I won’t do a good job.” [from The New York Times reporter Emma Goldberg interviewing a medical interpreter about her role at work in a column that has nothing to do with self harm.]

It may be difficult to accept the idea that self injury is a logical response to emotional distress, but it was long considered a appropriate medical treatment.

The medical history of treating mental illness with physical injury

The history of Western medicine is full of instances where physicians caused injury to their patients and prescribed self injury as treatment for symptoms that today would be diagnosed as mental illness.

Doctors prescribed bloodletting for all sorts of reasons, sometimes encouraging the loss of large quantities of blood for several days in a row. Doctors would cut their patients and instruct their patients in how to cut themselves or have a family member cut them as part of treatment. This was sometimes accompanied by having the patients ingest poisons to induce vomiting, in order to balance the humors.

Another common treatment for physical and mental health issues was blistering. This was accomplished by burning the skin with heated metal objects, pouring hot oil onto the skin, or applying chemical irritants. Mustard plasters were initially used in order to intentionally cause blistering.

The most ancient type of surgery is believed to be trepanning, the practice of scraping or drilling a hole in the skull. This was believed to allow evil spirits — responsible for emotional suffering and leading to problematic behavior — to be released.

These were accepted and respected medical treatments for emotional distress for hundreds and sometimes thousands of years. For more information on the history of medical horrors, read Quackery: A Brief History of the Worst Ways to Cure Everything.

Aversion therapy and medical use of self harm today

More recently, aversion therapy has been used to change people’s behavior by having them cause themselves pain. Whenever someone thinks of engaging in the forbidden behavior, they are told to hurt themselves by pinching themself, snapping a rubber band, causing an electric shock, or inducing vomiting. While this practice has become controversial recently, this remains a prescribed treatment in Western medicine.

Self harm as self expression and exploration

Self harm has a few things in common with bondage discipline sadism and masochism (BDSM), body suspension, and body art, but there are critical differences. BDSM, rope play, body suspension, and body art are all done in carefully controlled and safe environments. They are an exploration and celebration of physical sensation, power dynamics, and emotional experience. They are NOT self harm, self injury, or self mutilation.

People who engage in BDSM, body suspension, and rope play may have signs of injury like cuts, bruises, burns, and scratches.  BDSM is consensual role play that may or may not be sexual. Rope play involves tying someone up in a way that may be erotic or sexual. Body suspension involves suspending the body from hooks that puncture the skin. Injuries caused consensually and safely are not self harm or abuse.

Body art and scarification

Quite a few artists have modified their bodies as part of their work. Catherine Opie — who carved the word pervert into the skin on her chest and pierced her arms with a line of pins — might be the most famous. MUMOK has a whole floor of their museum devoted to the body art movement — which comes with extensive content warnings.

Outside of high art, the practice of scarification is considered body art and not self harm. Scarification uses cutting, burning, and branding to make patterns on the body much like tattooing.

These practices may be disturbing to some people, but they are generally safe. You may not understand someone’s choice to engage in these art forms, but there’s no need to be concerned about them.

I know, there are a bunch of Law & Order: SVU episodes and other crime shows that use autoerotic asphyxiation and weird sex stuff as the twist ending. But real life is not like what we see on TV. You may rightly be concerned about someone possibly harming themself through unsafe sexual practices, but that’s a different issue and not something discussed in this article.

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How to hold space for someone who is injuring themself

To hold space is to listen without judgement, to accept their truth as you listen, and to respond with empathy. It doesn’t mean sitting silently, waiting for someone to finish talking and then continuing on like usual. It means actively listening with empathy and the desire to understand their experience. You’re joining them in their world and empowering them to lead, not forcing them into yours or telling them what to do.

Let them set the tone of the conversation and remain in control of the experience. One way to do this is to mirror the language they use. If they say “cutting,” you should also refer to it as “cutting” and not “self violence,” “self mutilation,” or “self injury.” In fact, it’s best to avoid anything that sounds clinical and pathologizing unless that’s the terminology they use. You’re not their doctor or their therapist, you’re another person just like them.

Holding space requires respecting them. Unconditional support means you can feel anger, resentment, and disappointment towards them and still see them as a person who is equal to you, with their own experiences, hopes, and dreams, and the right to make their own decisions. Supporting someone unconditionally means there are no strings attached — you are choosing to be with them in this moment and they don’t owe you anything as a result of accepting your support.

Self harm isn’t the problem, it’s a way to cope with the problem. Whatever is causing the underlying emotions that someone is trying to cope with is the real issue. It’s probably not the kind of thing that can be “solved” in a single conversation. It’s not your responsibility to get them to stop injuring themselves or to fix how they feel. Your role is to be a caring friend and support them as they go through this experience.

Seeking to understand is not the same as approving

You don’t have to approve of their actions. Holding space for them means remembering they are a person of value and no action can change that. You don’t have to take their truth as your own, you just have to recognize that your truths differ and meet them where they are. Validating their experience isn’t an endorsement of it, it’s simply seeking to make sure you understand what they’re trying to say.

As tempting as it can be to show that you understand by sharing your own experiences, this tactic backfires. It shifts the focus of the conversation to you. The focus should be on them and their experience.

You may not be the right person to support them

Holding space for someone requires an awareness of your internal state and how that shapes your experience of the world. That requires not only general self awareness and self control, but the ability to hold space for someone in this moment.

That can be impossible to do if you’re currently exhausted or coping with your own struggles.

Sometimes the most supportive thing you can do for someone is respecting your own limits. It’s okay to tell someone “I want to support you, but right now I’m not in the headspace to do that.”

Disappointing someone by expressing boundaries is far better than hurting them by dismissing their feelings, arguing that their experience of the world is wrong, guilting them for upsetting you, or shaming for their struggles.

You can check in with them when you’re feeling capable of holding space as well as helping them find support from someone else.

Alternative ways to cope

The most important way to show someone support is to be with them in their moment of pain.

If someone is open to finding safer coping methods, your role is to provide guidance and support, not solutions. You can help them identify their strengths and put them to use coming up with their own ideas. You can help them be resilient by providing them the warm support of knowing someone cares about them and accepts them as they are.

You can’t know what will work for them, because you’re not them! The suggestions I list are things that other people have come up for themselves. They’re there to help you guide them to come up with their own ideas, not to tell them what to do.

Dealing with moments of panic and distress

If someone is harming themselves in a moment of panic, it might be helpful for them to explore grounding techniques. Some common ones include:

• 5-4-3-2-1
• Counting to 100
• Watching a breathing gif
• Going for a walk

If they try these or any other technique and still end up self injuring, that’s okay! It’s not a sign of failure, it’s a normal part of the trail and error process of learning what coping skills work for what situations. The fact that they tried a new way to cope is a sign of strength and bravery.

Turning their thoughts off

Meditation teaches us to accept and quiet our thoughts to find peace and contentment. Meditation also requires years of dedicated study to master, forcing us to face a lot of emotional challenges and inner baggage along the way. Cutting yourself, burning yourself, or even pinching yourself is a fast track to achieving a temporary feeling of peace.

The physical sensation of pain can be so overwhelming that it dominates our full attention, shutting out the rest of the world, including our internal experience. Who hasn’t pinched themselves to keep themselves from crying? It zaps you out of your mind and into your body.

Some people replace things like cutting, scratching, and burning with safer ways to cause pain, like holding an ice cube, snapping a rubber band around their wrist, or doing 100 sit-ups. Other alternatives might be anything that demands their full attention and makes them lose track of time, like video games, reading, and watching movies. And, of course, there’s meditation and yoga.

Releasing tension and anger

Some people experience an intense relief during or after injuring themselves. This is the same feeling that drives people to engage in compulsive sexual behavior and intense exercise.

Just like people talk about runners high or the thrill they get from a really challenging workout, there can be a certain euphoria from experiencing physical pain.

Explore other ways to help them release their energy and experience physical pleasure in order to identify ways to cope that don’t cause harm. Sometimes journaling helps people release energy. Other people sit in their car and scream, or find a way to let the tears out without having to injure themselves physically. What helps them release pent up energy? What brings them physical pleasure?

Feeling something, anything

When people are totally overwhelmed, sometimes they go numb to protect themselves. It’s like an emergency shut-off valve so we can get through the day. Psychiatrists often label this experience as depersonalization or dissociation. Sometimes people get stuck in this emergency mode and are left feeling numb, unable to access joy and pleasure. They’re left feeling empty and detached from the world and themselves.

Physical pain is a way to end this numbness, by helping people feel something. It can release the blockage that’s keeping them from accessing their own inner world and feeling connected to the outer world.

Explore what else helps them get unstuck. Some people create elaborate rituals to break through this metaphorical wall — including constructing stage set walls and literally breaking through them. Other people explore ways to change their routine so they feel less trapped and can escape the daily auto-pilot. Anything that taps into hidden emotions might help them feel like themselves again.

Making their emotional suffering visible

Some people harm themselves to demonstrate how great their suffering is when they’re overcome by the invisible pain of emotions. Some people want the people around them to see how much they’re hurting, while others take precautions to keep their behavior secret.

This need for someone to see and recognize their internal experience has been the motivation (and muse) for so many artists. People don’t need to have any special artistic talents in order to find satisfaction in picking up a paintbrush, camera, guitar, or pen.

I scoffed the first time I heard someone suggested people draw on themselves instead of cut, but since then quite a few people have said it’s helpful for them.

Punishing themselves and gaining control over a situation

We live in a world where people are punished for misbehaving, so it’s not a shock that some of us internalize that voice and find ways to punish ourselves. I wonder how many people who engage in extreme athletic challenges and highly restricted eating are motivated by the idea that they need to suffer to cleanse themselves of their misdeeds.

Causing ourselves physical pain is also a way to control how we feel. Because physical pain triumphs over emotional pain, we can stop being controlled by our response to other people’s actions by causing ourselves intentional injury.

When discussing this, be careful not to suggest that they should be punishing themselves or in control of how they feel. If this is what they’re dealing with, they’ll tell you.

While these are two separate issues, often they have similar safer alternatives. People might find that cleaning feels both like punishment and puts their world in order. Why do they feel like they need to be punished? What makes them feel accepted? Are their weaknesses related to their strengths? What happens if they lose control?

Expressing emotions

Many people grew up in homes where we were taught that expressing our emotions is unacceptable. Remember being told “if you don’t stop crying I’ll give you something to cry about!”? Family life, school, and work are full of experiences where we’re shamed for expressing our emotions.

When people aren’t comfortable expressing how they feel, those feelings tend to bleed out of us in ways that feel out of our control. Sometimes that involves causing ourselves to actually bleed.

Emotions are physical! Even if someone isn’t comfortable labeling something as anxiety, they can identify the physical sensations of the tightness in their chest, the burning cheeks, cramping stomach, cold hands, and racing heart.

People who harm themselves to provide an outlet for safely expressing their emotions can come up with creative ways to test out showing how they feel. They don’t need to become comfortable talking about how they feel with friends and family in order to cope in a safer way! Anonymous online support groups are incredibly popular for a reason. Some people find it helpful to simply name the emotions they’re experiencing. Others find it helpful to journal or sketch their thoughts, sometimes tearing the papers up when they’re done to keep it completely confidential.

Questions to ask about self harm

If the person you’re concerned about isn’t sure why they are self harming or can’t articulate what drives the behavior, ask them to explain how they feel before, during, and after.

If they want to stop the self harm behavior, ask them if they know what type of situations or feelings make them want to do it. Does it feel like something they can control? Have their been times when they had an urge to harm themselves and didn’t do it? How did they manage that?

If they’ve been coping by harming themselves for a while, have they always done it the same way? Do they have rituals around it? When did it start? Are there things that make it more or less effective?

You don’t have to limit the conversation to discussing self harm! You’re there to support someone you care about, not study their behavior. Who else in their life might be there to support and love them? What gives them a sense of purpose? What do they want their life to be like? What’s important to them?

Long-term solutions

Because self harm is a way of coping, the most effective way to reduce the likelihood of the behavior is to address the underlying issue. Depending on the situation someone is in, there are many different ways to support them.

One great free tool for increasing resilience is SuperBetter, which is both an online community game and a book.

People address problems and reduce stress in all sorts of ways, from changing careers to embracing a spiritual practice. It’s easy to tell someone to gain self-awareness, love themselves, and live by their values, but most of us live in situations where at least some of the factors that influence our mental health are out of our control.

Protective factors for mental health

• Getting enough sleep
• Eating nutritious foods
• Engaging in enjoyable forms of exercise
• Spending time outdoors
• Having friends and family who accept you as you are
• Having a safe place to live and stable income to provide for your needs
• Having an awareness of the values that guide your choices
• Engaging in activities that allow you to feel a sense of purpose
• Having the ability to make decisions in your own life

Getting support from a professional

If someone is open to getting professional help, there are several ways you can show your support.

Going to therapy can be intimidating. Understanding what to expect can make it easier for them to feel comfortable making that first appointment. The most common therapeutic treatments for non-suicidal self-injury (NSSI) are dialectical behavior therapy (DBT) and psychodynamic therapy.

There’s a lot of administrative work involved in accessing healthcare. You can let them know if you’re willing and able to help them tasks like figuring out what therapists are accepting new patients, take their insurance, and offer care at rates they can afford.

Therapy isn’t a quick fix. People may not find therapy helpful, especially if they’re being forced to go. You may want to let your friend know you don’t expect therapy to change their behavior right away and you’ll continue to be there to support them, even if they decide to switch therapists or stop going.

Keeping them physically safe

It makes sense to be concerned about someone’s physical safety then they’re practicing self harm. Some self harm behaviors can cause critical injury or death, intentionally or not.

Some ways to help keep someone physically safe are:

• Provide them with a first aide kit so they can keep wounds clean
• Ask them to tell you if they accidentally harm themselves more than they meant to or need medical attention
• Offer to go with them to an urgent care clinic or ER if they need medical attention
• Encourage them to contact a crisis hotline for support:
  • In Canada: call 1-833-456-4566 or text 45645 for Crisis Services Canada.
  • In the US: call 1-800-273-8255 for the US Suicide Prevention Lifeline. You can also text 741-741 for free, 24-hour support from the Crisis Text Line.
  • Outside of the US and Canada: visit the International Association for Suicide Prevention to find resources in your area.

Getting professional help without their cooperation

Growing up, many of us are told to contact “the authorities” if someone is in need of help. Depending on the situation, this might mean telling a teacher, faith leader, social worker, child welfare officer, police officer, or contacting 911. This is an action that cannot be undone and requires careful consideration.

Reporting someone to the authorities breaks their trust and can cause irreparable harm to your relationship with them. Our healthcare system often provides poor quality care and many people are traumatized by the experience of involuntary treatment.

In Hello I Want to Die Please Fix Me, Anna Mehler Paperny recounts that the 911 call an acquaintance made didn’t end up connecting her with any follow-up care beyond a list of phone numbers and a handful of sleeping pills, which she promptly used to try to end her life. Coworkers and friends who heard about the police being sent to her home on a wellness check ultimately saved her life by going to her home themselves and contacting the police a second time. While she ultimately received help and recovered, she remains conflicted by this violation of her privacy. The shame of her public humiliation and involuntary treatment lingers.

Calling 911 for someone experiencing a mental health crisis can lead to violence and death, because police officers are rarely trained in handling these situations and are primed to respond to perceived threats with escalation, domination, and violence. This is especially important if the person you are concerned about is BIPOC, has communication differences, or has anything that may be viewed as a weapon in their possession.

If you find it necessary to contact the authorities for someone in a mental health crisis, reach out to your local mental health crisis center to determine the safest way to get emergency help.

Attention seeking and emotional manipulation

You might be in a situation where someone is harming themselves in order to compel you to do something. While this behavior can be seen as emotionally manipulative, it can also be seen as someone in extreme distress seeking the help they need.

Are they making their pain visible to demonstrate how desperately they need help? Or is someone harming themselves in order to punish you? It might be both.

You are not responsible for someone else’s internal emotional experience. You cannot change how someone else feels or “fix” their problems, no matter how much they might want you to. If someone is harming themselves in order to demand you help them, you are both in a dangerous situation.

Someone else’s needs don’t negate your own. Supporting someone else often requires determining the ways you can be there for them while also taking care of yourself. The person you’re trying to help may resist respecting your boundaries and resent you for it. There are rarely clear answers about what you should do. You have to make the right choices for yourself in any given situation. Sometimes all of our options come with their own issues.

Consider getting your own support and guidance from a therapist, especially if the person you’re seeking to support is a family member or someone you share a home with.

Someone’s behavior may be motivated by their own suffering and needs, but that doesn’t negate the harm it can cause you. Everyone in a crisis deserves support, but that doesn’t mean you are able to provide that support or responsible for providing it. Respecting your own needs and limits is a critical part of supporting someone else.