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Social media a double-edged sword for young persons who self-harm, as counsellors see more cases during Covid-19 pandemic

SINGAPORE — Undergraduate Lauren Koh was 13 years old when she started cutting her forearm and thigh with a penknife intentionally. As she looked at the blood and felt pain, she would feel the anxiety from all that was going wrong in school and at home dissolving.

Social media a double-edged sword for young persons who self-harm, as counsellors see more cases during Covid-19 pandemic
  • Some children and youth are inflicting injuries on themselves as a way to cope with emotional pain and stress
  • Some cases that experts have seen are as young as nine to 12 years old
  • Disruptions to routine and psychological stress during the Covid-19 pandemic may exacerbate the habit
  • Social media use and peer influence may also increase self-harm risk
  • A 22-year-old undergraduate tells why she started cutting herself at the age of 13

SINGAPORE — Undergraduate Lauren Koh was 13 years old when she started cutting her forearm and thigh with a penknife intentionally.

As she looked at the blood and felt pain, she would feel the anxiety from all that was going wrong in school and at home dissolving.

She began doing this regularly, sometimes every day, whenever she was in a depressed mood.

“When I hurt myself for the first time, I noticed that together with the effect of getting people’s attention, it also helped to relieve the anxiety. When there’s physical pain, the feeling of panic somehow decreases,” Ms Koh, now 22, said.

“I also felt that seeing myself bleed was important in the whole process. I’m now still trying to establish why that’s the case, as a psychology major.”

Young people who inflict themselves with physical injuries is not a new occurrence. They may slash their own arms, staple their skin, sear themselves with cigarette butts, or hit, bite or slap themselves.

Experts told TODAY that such maladaptive ways of coping with emotional pain are common among troubled children and youth whom they see in their practice. These harmful habits have worsened during the Covid-19 pandemic, they observed.

Some of these cases are as young as nine to 12 years old, although most tend to be in their teenage years and are in young adulthood.

Dr Donovan Lim, a senior consultant with the department of developmental psychiatry at the Institute of Mental Health (IMH), believes that the pandemic may have exacerbated such self-injury practice.

The pandemic has changed how people live and interact with others, he said. Together with the economic impact on individuals, families and society, the disruptions have led to a collective increase in psychological stress.

For teenagers who thrive on peer and school support, the reduced interaction may heighten loneliness and isolation.

(Young persons') emotional pain can be from friendship issues... or stress from school and parental expectation. The high expectations can also come from themselves. They feel they are not good enough.
Ms Cynthia Ho, counsellor with Reach Counselling Service

Ms Cynthia Ho, a counsellor with Reach Counselling Service, has seen about a 10 to 20 per cent increase in self-harm cases since the start of the pandemic in 2020.

Many children and youth who do this use physical pain to ease their emotional turmoil, which they may have difficulty expressing.

“Their emotional inner pain is so unbearable that they have to turn to something else to replace it, to find a way to cope.

“Their emotional pain can be from friendship issues, not being able to blend into social settings, or stress from school and parental expectation.

“The high expectations can also come from themselves. They feel they are not good enough,” Ms Ho added.

“There was a 15-year-old teenager who told me, ‘I have to start thinking about my future and job now. I need to be a psychologist or lawyer to help others.

“At the age of 15, this kid is thinking very far ahead… I suspect maybe it’s society, the environment as a whole that have led to these ‘invisible’ self-expectations to do well, do better."

When things don’t work out well on social media, (young people) may feel isolated and unsupported, which in turn increases the risk of self-harm for those who are susceptible.
Dr Donovan Lim, senior consultant with the department of developmental psychiatry at the Institute of Mental Health

Along with being indoors where much time is spent on online activities, the increased use of social media have exposed children to self-injuring behaviour and some may even want to try it.

Dr Lim from IMH said that the internet is fraught with misinformation and questionable advice.

“There are websites that deliberately encourage self-harm acts, which are targeted at youth, and some teens are using social networking platforms to build entire communities based on self-cutting.”

He added that teenagers who use social media excessively lose opportunities to develop positive real-life connections.

“When things don’t work out well on social media, they may feel isolated and unsupported, which in turn increases the risk of self-harm for those who are susceptible.”

Social media is a double-edge sword for at-risk youth, the experts said.

Even though it has a negative influence, online resources and communities can support and connect young people who struggle with self-harm. Documenting their mental health journey on social media can also be therapeutic for some people. 

Ms Koh the undergraduate said that there were moments during her teenage years when social media was detrimental to her mental health.

“I didn’t have the emotional maturity to curate what I put online and others also didn’t have the sensitivity to know what they should or should not say.”

That has changed in recent years, especially since she entered university.

Apart from her public social media account, she uses a private Instagram account to connect with close friends.

“If I’m in a difficult spot and need someone to talk to, but I’m not sure if I’ll bother anyone and make them feel obligated to listen to me (when I message them on the phone), I will post on my private account to say, ‘Hey, if anyone is up for a chat and can emotionally take it, I’d like to speak to somebody because I’m not in a good place at the moment’. That has allowed people to reach out to me,” she said.

Ms Koh finds that putting up posts or articles online to explain mental health conditions can be helpful, too. “The comments section of these posts has also let me feel that I’m not the only one feeling in a certain way, and made me feel less alone."

Ms Ho from Reach Counselling Service said that people are becoming more forthcoming in seeking help to manage their mental health.

This is partly due to a greater awareness of mental health problems and peers encouraging their troubled friends to get help.

That said, like the use of social media, peer influence can also be negative, and young people may pick up self-harming behaviour as a “trend” to vent emotions, she added.

Ms Celynn Chang, senior counsellor and manager of the Clinical Intervention Centre at Boys’ Town, said: “I have had clients who told me that their friends posted on social media photos of parts of their bodies where they have practised self-harming. Exposure to such content could be a risk for self-harm or suicide for vulnerable audiences.”

Dr Lim from IMH said that repeated exposure to self-harm imagery such as freshly cut wounds may also normalise such behaviour and reduce the motivation for treatment.

Ms Koh the undergraduate is mindful of what she posts on social media, especially on her public account. She has never posted photos of her cuts and steers away from saying things online such as “I’m going to hurt myself now”.

“While I’m all for de-stigmatising self-harm and mental illness, I think that it needs to be acknowledged that self-harm is not something that people are comfortable with. I feel that (such content) makes people more afraid and drives help away,” she said.

“I also don’t think it is a good idea to share pictures of your cuts on social media. Some people may argue it’s their way of coping but I feel it’s not productive and triggers people unnecessarily.

“If you feel that posting pictures of your self-harm helps you feel better or track what is going on, then I suggest setting up a completely private account with zero followers,” she added.

WHY THEY HARM THEMSELVES

A common misconception about self-harm is that the person is trying to end his life.

Ms Chang from Boys’ Town said that there are many reasons why young people turn to self-harming behaviour, and everyone has a different reason. The youngest case she has seen is a nine-year-old child.

“One major reason is that they have found it to be an effective coping strategy for quick relief of emotional pain and distress.”

Instead of the more ‘sophisticated’ methods that older teenagers use, younger children may bang their heads against the walls, pull out their hair... or slap themselves — often in an attempt to lessen or communicate emotional distress.
Dr Donovan Lim from the Institute of Mental Health

Paradoxically, inflicting pain through self-injury may have a “painkiller effect”.

This is due to the rush of endorphins that produce a natural “high”, which helps the troubled person feel emotionally better, Dr Lim from IMH explained.

“But just like the ‘high’ produced by drugs, the endorphins and the accompanying sense of well-being or euphoria is transient and can be addictive, making the teenager more likely to inflict self-harm again,” he said.

Other reasons for self-harm include punishing or distracting oneself, to regain a sense of control when there is a feeling that everything is out of control in one’s life.

For some youth, Dr Lim said that self-harm also functions as a desperate cry for help. However, this should not be misconstrued as “attention-seeking” or “manipulative behaviour”. 

Self-harming habits have been observed in adolescents who suffer from personality disturbances, depression, anxiety disorders, post-traumatic stress disorder, substance misuse, eating disorders and psychotic disorders such as schizophrenia.

“Self-harm may also be practised by adolescents who have no diagnosable mental illness, where it is seen as an ‘acceptable’ or peer-endorsed way to manage negative feelings, solve a problem or cope with a difficult situation,” Dr Lim added.

HOW THEY HURT THEMSELVES

Dr Lim said that by the time a child or teenager receives medical attention, the self-harming behaviour may have gone on for quite some time.

Self-harm seen in adolescent patients at IMH typically manifests in two ways.

They injure themselves, most commonly via self-cutting; sometimes by searing their skin with cigarette butts.

They may also deliberately poison themselves. This commonly occurs via an overdose of over-the-counter medications.

“Sometimes, the patients may overdose on medications prescribed for treatment of their mental health condition, which is why we strongly advise caregivers to safe-keep all medications.

“In other cases, the teenager may ingest household substances such as detergent,” Dr Lim said.

Lower primary school children may also show self-harming behaviour.

“Instead of the more ‘sophisticated’ methods that older teenagers use, younger children may bang their heads against the walls, pull out their hair, bite, scratch, punch or slap themselves often in an attempt to lessen or communicate emotional distress,” Dr Lim added.

“Some of these children may later progress to non-suicidal self-injury as they get older.”

WHAT SHE COULD NOT EXPRESS VERBALLY 

Despite intentionally cutting herself regularly in the past, Ms Koh said that ending her life was not on her mind. With hindsight, she sees that her self-inflicted wounds during her early teenage years were a cry for help.

At the time, she was being bullied in school and her parents’ relationship was going through a rough patch. She found it difficult to communicate with her parents.

Diagnosed with attention deficit hyperactivity disorder when she was 18, Ms Koh also had trouble regulating her emotions — which might have contributed to her self-harming behaviour.

“There’s a lot of negative stigma about self-harming for attention. But in many instances, I came from a place of needing help and not knowing what to say for (my teachers) to pay attention to me,” she said.

“So it felt like the best way to do it was to be in a position of physical harm, so someone would start that conversation and ask me what’s going on.”

Ms Koh confessed to feeling “a bit scared” when she started cutting herself, although that has changed over the years.

“At 13, you may not understand at what point does (self-harm) become fatal. There was the thought of, ‘What if I do something that cannot be reversed? What if I die?’

“Now, it’s no longer as frequent. To get myself off the edge, I’d just hurt myself enough to calm down from a panic attack.”

Some of the scars from cuts are still visible on Ms Koh’s arm and thigh but she is not self-conscious of her past.

She considers herself to be “more stable than usual” these days and has found alternative ways to cope.

For example, when she has the urge to hurt herself, she would call someone to talk, immediately do some sprinting or run a blade across play dough, an arts and craft modelling compound.

A person moulding pieces of play dough.

Ms Koh decided to take up psychology in university after taking up several internships in the mental health sector.

“I found a lot of purpose when I could help people navigate their issues. It gave me strength,” she said.

Being in an inclusive environment and around people who are accepting has also helped her open up about mental health problems.

“Currently, where I am interning (at a therapy clinic), we talk about emotion-focused issues so I’m not ashamed about it.

“No one has been ‘weird’ about it but I may be more self-conscious if I were in a less accepting environment.”

HOW TO SUPPORT A FRIEND OR LOVED ONE

When asked how may one support a loved one who is struggling with mental health problems, Ms Koh said that comments such as “You will get better”, “Time will heal” or “Stay positive, look on the bright side of things” are not helpful.

“I don’t think anyone who has said such things mean them in a negative way. They just don’t know it can be potentially patronising to people going through mental struggles.

“It’s always challenging to know what to say. But if someone discloses to you that they are hurting themselves and they feel really bad, a response could be, ‘Is there anything I can do to help you?’.

“Positively affirm them for being open to you and acknowledge that talking about it is a brave thing to do,” Ms Koh suggested. 

BREAKING THE SELF-HARM HABIT

Ms Cynthia Ho, a counsellor with Reach Counselling Service, said that many adults and parents are stumped and at a loss when they find out that their children are cutting themselves

The parents may not be equipped with the skills on how to approach the matter with their child, but early intervention is important when addressing mental health issues, she said.

Dr Donovan Lim, a senior consultant with the department of developmental psychiatry at the Institute of Mental Health, said that the attitudes of parents and school personnel such as teachers and school counsellors are critical when supporting the child.

He also said: “A punitive, invalidating or judgemental attitude not only strains relationships but may be distressing for an adolescent who is struggling with self-harm, even triggering an occurrence. The result could be more self-harm to relieve the distress and more determined attempts at secrecy, which ultimately thwarts treatment efforts.”

Ms Celynn Chang, senior counsellor and manager of the Clinical Intervention Centre at Boys’ Town, said that treatment would depend on the child’s specific issues and any related mental health condition he or she might have, such as depression.

If the self-harming behaviour is associated with the mental health condition, the treatment plan typically focuses on that condition.

Medications may be used to treat co-existing or underlying psychiatric disorders.

Psychotherapy, in the form of psychological counselling or talk therapy, can also help youth identify and manage problems that trigger their self-harm behaviour.

Ms Chang and Dr Lim both said that some helpful individual therapies include cognitive behavioural therapy and dialectical behavioural therapy.

They are focused on helping the youth acquire skills to process and regulate their emotions, cope with stressors, modify negative thoughts, manage distress, improve social skills and develop healthy problem-solving skills — with the aim of reducing the need for self-harm in the longer term.

Family and group therapy is also recommended, if the youth is open to it, Ms Chang said.

“How well treatment will work also depends on the level of support from family and people around them. We should not underestimate the power of human connection as a coping strategy,” she added.

Ms Chang emphasised that even if individuals who engage in self-harm may not intend to end their lives, they are at risk of suicide due to the frequent and habitual self-harming acts and an increased threshold of pain.

Dr Lim said: “Studies have shown that chronic self-harm is a predictor of subsequent suicidal attempts. We have observed that adolescents who come to us with suicide attempts often have a significant history of self-harm.”

WHAT PARENTS CAN DO

Be non-judgemental

Validate the child’s emotions and provide empathy so that the child does not feel judged, Ms Chang said. This will help encourage open conversations.

Ms Ho advises parents and adults not to jump into conclusions and offer advice too quickly, without first showing that they care for the child.

Remain calm  

Ms Chang said that children and youth often observe how adults around them react. If you panic, it may cause more emotional distress.

Do not make threats, yell or shame them. Create a safe space for them to talk about their struggles.

Encourage healthier ways to relieve and manage intense emotions

For example, go for a run or walk, or engage in art, journalling, meditation and other activities that they enjoy, Ms Chang said.

Seek professional advice

If the youth expresses thoughts of suicide, Ms Chang advised staying with them and seeking professional advice or help immediately.

Ms Ho said that parents should also talk to the school counsellor if they notice red flags in behaviour such as increasingly frequent emotional meltdowns or aggressive behaviour at home to ventilate emotions, such as punching the wall or table.

“If the child says things like, ‘I’m going to die’, ‘I’m going to jump’ — these are clear red flags,” she added.

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self-harm mental health social media Covid-19 children teenagers Youth parents

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