This article was developed as part of the psychoeducational initiative of Emotional Consult in support of parents and professionals. A shorter adapted version has been published in EduChain with a focus on practical guidance for parents.

Self-harm in adolescents is often not a desire for death, but an attempt to manage pain that seems unbearable. Understanding the experiences behind this behavior is the first step toward restoring the connection between the child and their loved ones.

When the Parent Sees the Wounds, but Not the Pain Behind Them

A mother notices several thin lines on the arm of her 15-year-old daughter. Her first thought is: "She wants to die!". The next: "Where did I go wrong?". The child is silent. The parent cries. Fear stands between them.

These questions are natural. They do not speak of a bad parent, but of a parent who suffers alongside their child. It is important to know that self-harm is rarely the result of one specific cause or one single mistake. It is the result of a complex interaction between personality traits, experienced events, relationships, mental health, and the way the young person manages to cope with their emotions.

Such situations happen far more often than we imagine. In recent years, specialists have recorded an increase in cases of self-harm among adolescents. For many families, this is one of the most frightening experiences, because it seems inexplicable: "Why would they cause pain to themselves?". This question, however, leads us in the wrong direction. It is more useful to ask: "What pain is this child trying to bear?". Herein lies the difference between judging a behavior and understanding the person behind it.

Self-Harm – An Attempt to Bear the Unbearable

Self-harm (in English, non-suicidal self-injury – NSSI) refers to the deliberate causing of damage to one's own body without suicidal intent (American Psychiatric Association, 2022). Most commonly these are cuts, scratches, burns, or blows. It is important to emphasize that self-harm and a suicide attempt are not the same thing, although they can coexist and always require professional assessment.

Among adolescents, they are among the significant challenges to mental health, which is why early prevention and access to support are key priorities (World Health Organization, 2020). In the DSM-5-TR, self-harm is included as a condition for further study, which underscores the need for clinical assessment but does not define it in itself as a separate mental disorder.

Research shows that a significant percentage of adolescents have at least once gone through a period in which they resorted to self-harm. It most often begins in early or middle adolescence, with onset frequently observed between the ages of 12 and 16 (Nock, 2014). This means that in many school communities there are young people experiencing similar difficulties, often without those around them being aware of it.

What Drives a Young Person to Direct Pain Toward Themselves?

At first glance, this seems illogical. But when we examine the psychological mechanisms, the picture becomes more understandable.

What Lies Behind Self-Harm? The Science of Pain, Emotions, and Coping

Contemporary research shows that the most common function of self-harm is the regulation of extremely intense emotions that the adolescent struggles to bear (Nock, 2009). Today we know that self-harm is rarely solely an attempt to attract attention, but more often a signal of significant internal suffering. Research shows that immediately before the act of self-harm, young people often experience intense anxiety, anger, shame, a sense of emptiness, or emotional overwhelm. For a brief moment, physical pain reduces the intensity of psychological pain. Some adolescents describe that for the first time in hours or days "they are able to catch their breath". Others say that physical pain is the only thing that makes them feel they still exist.

This does not mean that self-harm is a healthy solution. It means that in that moment it is the only known way of coping.

After self-harm, many of them describe a brief sense of relief, which, however, quickly gives way to guilt, shame, and self-criticism (Klonsky, 2007). In this way, a vicious cycle gradually forms – painful emotions lead to self-harm, and self-harm generates new painful emotions.

Scientific data shows that there is no single cause for this behavior. Most often it arises from the interaction of several factors – heightened emotional sensitivity, difficulties in emotional regulation, experienced bullying or rejection, family conflicts, psychological trauma, anxiety or depressive states, low self-esteem, and a sense of loneliness (Cipriano et al., 2017). For some adolescents, the decisive factor is the feeling that there is no one with whom they can safely express their pain.

It is important to emphasize that self-harm is not a diagnosis. It is a symptom that can accompany various mental conditions, but it sometimes also appears in adolescents without a psychiatric diagnosis. What they share in common is not the behavior itself, but the difficulty of bearing and making sense of their experiences.

When Emotions Become Too Heavy to Carry

A particularly important finding of contemporary research is the role of emotional regulation. Children are not born with the ability to recognize and regulate their feelings – they develop it gradually through relationships with significant adults. When the child repeatedly experiences that their emotions are understood, named, and accepted, they gradually begin to recognize and regulate them on their own. When this does not happen, strong feelings may remain without an inner "container" and be experienced as something threatening to overwhelm them.

Here an important idea emerges that connects contemporary science with psychotherapy – behind self-harm there is no desire for pain, but a striving for relief. As paradoxical as it may sound, physical pain temporarily becomes a way of managing psychological pain.

When the Psyche Speaks Through the Body

While contemporary research focuses on the functions that self-harm serves, the psychodynamic perspective raises another important question: "What does this behavior mean for this particular person?"

Self-Harm as a Message: What the Young Person Is Trying to Say

In the psychotherapeutic tradition, the symptom is not viewed as accidental (Peseschkian, 2003). In positive psychotherapy, it can be understood as a person's attempt to cope with an internal conflict and to restore balance between different aspects of experience (Fileva-Hadzhova, 2026). The meaning of the symptom is different for each person and can only be understood in the context of their personal history (Freud, 1990).

From this point of view, self-harm is not merely an action, but a form of communication – a way of expressing something for which there are not yet words. In some psychodynamic understandings, it may be connected with self-directed aggression, in which internal tension and destructive impulses are turned toward one's own body rather than toward the external world (Menninger, 1938).

The child's ability to bear and organize their own experiences develops in the context of early relationships with the caring adult (Winnicott, 2008). When the child or adolescent experiences emotions that cannot be shared, understood, or borne by the significant people around them, these experiences may remain isolated and difficult to make sense of.

Emotional development also depends on the adult's capacity to receive the child's chaotic experiences, give them meaning, and gradually help them be transformed into thoughts and words (Bion, 1962). When this process is impeded, part of the emotional experience may remain unexpressed and find its way to the body rather than to language.

From this perspective, self-harm is not simply a symptom that must be eliminated. It is the psyche's attempt to cope with pain that cannot yet be named, understood, and shared.

This is also the reason why therapy is not directed solely at getting the adolescent to stop self-harming, but toward gradually finding words for the pain and building other ways of expressing it, without it being directed toward one's own body. When pain receives a name and is shared in a safe relationship, the need for the body to "speak" in place of the psyche may gradually diminish. The symptom is not an enemy that must simply be eliminated, but a message that must be understood.

It is important to emphasize that this does not mean parents should be blamed for their child's self-harm. Such behavior arises as a result of a complex interaction between many factors, and it is precisely in relationships – with parents, the therapist, and other significant people (Bowlby, 2006) – that a space for change can be created, in which the pain can gradually be transformed into an experience that can be thought about, expressed, and shared.

How Parents Can Be a Source of Support When Their Child Self-Harms

In therapeutic practice, a painful paradox is frequently observed. On one side stands an adolescent, convinced that no one can understand them. On the other – parents who want to help but do not know how. Both feel powerless.

To better understand this difficulty, it is important to remember that adolescence itself is a period of significant internal changes. It is a time in which the young person gradually separates from their parents, builds their own individuality, and seeks answers to the questions "Who am I?" and "Where do I belong?" (Blos, 1967; Erikson, 1996). This natural need for autonomy can sometimes be experienced as distancing from loved ones, especially when strong emotions, internal conflicts, or a sense of loneliness are added to it.

In these moments, parents face the difficult task of finding a balance – respecting the adolescent's need for independence without losing the emotional connection with them.

Not Control, but Connection: How to Be There for the Adolescent in a Difficult Moment

Fear often causes parents to react impulsively – to constantly monitor their child, to remove all sharp objects, or to insist that they promise "never to do it again". Sometimes accusations, threats, or attempts to minimize their pain with words like "there is no reason to feel that way" appear.

Although these reactions come from love and anxiety, they rarely reach the adolescent's true experience. When a person is flooded with unbearable emotions, they need not so much ready-made solutions as presence – someone who can remain beside them without judgment.

The child does not need perfect parents. They need parents who can stay close to them even when their pain is difficult to understand.

What Supportive Help Actually Looks Like

Sometimes one calm remark has more power than dozens of questions: "I can see that things are very hard for you. I don't know exactly what you're going through, but I want to understand you. You won't go through this alone."

This does not mean self-harm should be accepted or underestimated. It must always be taken seriously and professional help must be sought. But it is important for the adolescent to feel that the parent sees not only the behavior, but the person behind it.

The restoration of trust does not begin when the parent finds all the right answers, but when the child feels that they no longer carry their pain alone.

From Pain to Words: How Psychotherapy Helps

One of the most widespread myths is that the goal of psychotherapy is simply to stop the self-harm. Although ending this behavior is an important part of the process, the true goal is to understand the suffering that lies behind it.

If the symptom is eliminated without its function being understood, the internal tension may find another way to express itself. This is why therapy does not focus solely on the behavior, but on the young person's experiences.

The therapeutic process creates a safe space in which the adolescent can gradually speak about fears, anger, shame, loneliness, or a sense of rejection, without being judged. Over time, they begin to recognize their emotions, understand what triggers them, and build healthier ways of coping.

Contemporary research shows that improving emotional regulation, building secure relationships, and developing adaptive coping strategies are among the key factors in the lasting reduction of self-harm.

Working with parents is also an important part of the process. They do not receive instructions on how to be "perfect," but support in better understanding their child's experiences and finding more effective ways to be there for them.

Regardless of whether the therapeutic approach is psychodynamic, positive, cognitive-behavioral, or integrative, the goal remains the same – for the adolescent to gradually move from action to reflection, from loneliness to connectedness, and from pain expressed through the body to pain that can be shared in words.

True change is not measured solely by the fact that the self-harm has stopped. It occurs when the young person begins to believe that there are other ways to cope with their suffering – without harming themselves and without remaining alone with it.

When Pain Finds Words, Hope Returns

Self-harm provokes fear, confusion, and helplessness. It frightens parents, worries teachers, and often remains misunderstood by peers. But behind every mark on the skin stands a person trying to cope with an experience for which they have not yet found words.

When we see only the symptom, we risk missing the story behind it. Understanding the fear, loneliness, shame, or sense of rejection that lie behind the behavior is the first step toward change.

Self-harm is not an inevitable part of growing up and must not be minimized. It is a signal of suffering with which the adolescent cannot cope alone. Timely psychological and psychotherapeutic help can assist pain in finding another way of expression.

In therapeutic practice, we often witness how young people who initially cannot speak about their experiences gradually begin to tell their story. Where there is initially silence and shame, trust, understanding, and the ability to share the most difficult feelings can emerge.

Parents do not need to have all the answers. The most valuable thing they can give their child is the willingness to remain beside them when they are suffering, and the courage to seek help when they cannot manage on their own.

The most healing question is not: "Why did you do it?", but: "What were you going through that made you feel you had to do it?". In this question there is no accusation. There is curiosity, compassion, and a desire to understand.

I believe that behind every behavior there is a story that deserves to be heard. When we help a young person find words for their pain, other possibilities for expressing it also gradually emerge – without the body remaining the only means of communication. This is one of the deepest meanings of psychotherapy – for suffering to cease to be something a person carries alone and to be transformed into an experience that can be shared and gradually overcome.

If you recognize such signs in your child, do not remain alone with your anxiety. Self-harm is a signal of suffering that deserves attention and understanding. Timely consultation with a specialist can help restore dialogue, trust, and a sense of safety within the family.

References

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Blos, P. (1967). The second individuation process of adolescence. The Psychoanalytic Study of the Child, 22(1), 162–186. https://doi.org/10.1080/00797308.1967.11822595

Bowlby, J. (2006). A Secure Base. Routledge Classics.

Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal self-injury: A systematic review. Frontiers in Psychology, 8, Article 1946. https://doi.org/10.3389/fpsyg.2017.01946

Erikson, E. H. (1996). Идентичност: младост и криза. София: Наука и изкуство.

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Menninger, K. (1938). Man Against Himself. Harcourt, Brace & World.

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Nock, M. K. (Ed.). (2014). The Oxford Handbook of Suicide and Self-Injury. Oxford University Press. https://doi.org/10.1093/oxfordhb/9780195388565.001.0001

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