By Meghan Vivo One of the biggest obstacles in treating people who self-injure is the toxic shame they feel as a result of their self-harming behaviors. The secrecy inherent in self-harm also creates obvious challenges for concerned friends and family, who may not know the depth of the person\u2019s emotional pain until the problem has escalated. \u201cPeople who self-harm feel a lot of shame,\u201d says Amanda Elkin, LPC-MSHP, CSAT-S, CMAT-S, a licensed professional counselor and program director at The Ranch rehabilitation center in Tennessee. \u201cMany go to great lengths to hide their wounds and scars, fearing others will label them as \u2018crazy,\u2019 push them away, or otherwise respond with judgment, horror or disgust \u2013 all of which further isolates them from the support they need to get better.\u201d Understanding the feelings that fuel self-injury and learning constructive ways to help, without adding to the shame, allows loved ones to lend critical support in the person\u2019s healing process. Is There a \u2018Typical\u2019 Cutter? Most people picture someone who self-harms as a teenage girl that cuts her forearms. But according to Elkin, that\u2019s a stereotype. Although she does treat young girls who self-injure, \u201cself-harm can look like a lot of different things,\u201d she says. \u201cWe treat both males and females who self-harm in different ways and in different places.\u201d For example, Elkin says recently she has noticed self-harm affecting younger populations. And her clients often self-injure on the inner thigh, hip, stomach or shoulder \u2013 not the forearm \u2013 because those are areas they can cover up even in summer clothes. Although people frequently talk about cutting, it\u2019s just one of many types of self-harm. \u201cLoved ones and treatment professionals may not be able to tell the person is intentionally self-harming.\u201d For example, Elkin has treated people who smashed their hand with a hammer, hit inanimate objects, burned themselves with cigarettes, or banged their head against a wall. A person can self-harm without ever leaving a mark or bruise, which can make intervention and treatment difficult. Why Do People Hurt Themselves? For some, self-harm is tied to body dysmorphia or an eating disorder; that is, they may self-injure on their stomach or thigh because they dislike that area of the body. Some are trying to cope with early life trauma or mistakenly believe they are at fault for abuses they\u2019ve endured and are self-punishing. Some may be struggling with underlying depression, a personality disorder or another mental health issue. For many people, self-harm is a way to express difficult feelings. \u201cSeeing blood means they\u2019re still alive and whatever is causing them emotional pain hasn\u2019t killed them yet,\u201d Elkin says. Sometimes it\u2019s a cry for help, but sometimes it\u2019s not. In studies, researchers have found that both self-injurers and non-injurers report feeling \u201cpain offset relief\u201d \u2013 even euphoria of sorts \u2013 from self-harm behavior. And in rat studies, over time the subjects began to associate a specific pain stimulus with pain relief and came back for more. Researchers concluded that people who self-injure aren\u2019t unusual or different in their perception of pain, they\u2019re tapping into a natural pain management system that lives in all of us. However, people who self-harmed did show signs of negative self-image, describing themselves as defective, bad, or deserving of punishment or criticism. When provided with interventions that raised their sense of self-worth, the participants became less willing to endure pain. So, for many people, self-injury validates their image of themselves as being \u201cbad\u201d and becomes a way to cope with a poor self-image and other difficult feelings. How to Help a Loved One Who Self-Harms If you notice signs of self-harm, Elkin has a few tips for how to help without feeding the shame cycle: Approach the person with an attitude and voice of love and concern. For example, \u201cI\u2019m worried about you. I\u2019ve noticed we don\u2019t spend time together lately\/you\u2019ve been withdrawn, and I\u2019m really sad about that coming in the way of our relationship. Do you want to talk about it?\u201d Let them know you\u2019re open and ready to talk about whatever, whenever, and that you\u2019re willing to have those tough conversations. Don\u2019t ignore the behavior, but don\u2019t shame the person either. \u201cIt\u2019s a difficult balance to strike \u2013 being able to share your concern without sending a message that the person is bad or doing something scary or wrong,\u201d says Elkin. See their pain. If you\u2019re concerned about an adult friend or loved one, \u201cbe there to hold space and let them know you see them \u2013 not just the self-harm behavior, but who they are, including their pain and need for love and support,\u201d says Elkin. Keep morality, ethics and religion out of the conversation. It\u2019s difficult to understand why someone so special in your eyes could possibly hurt themselves on purpose. In an attempt to make the behavior stop, loved ones may call upon family values or other methods of shaming the person into quitting. But self-harm is about emotional pain, not the quality of a person\u2019s moral character or their beliefs. \u201cThe person probably already knows what they\u2019re doing goes against their own value system and feels conflicted about that,\u201d says Elkin. \u201cTelling someone self-harm is against the family\u2019s religion or ethics only puts them further in the shame pit, which makes them less likely to stop the behavior or reach out for help.\u201d Recognize positive behaviors. Although it often comes more naturally to focus on the negative behaviors that concern you, \u201cgive attention in positive ways rather than allowing the self-harm behavior to become all-consuming,\u201d suggests Elkin. \u201cThis way the person struggling with self-injury learns they can trust you with their pain.\u201d Get help. If you\u2019re a parent concerned about your child, Elkin recommends seeking medical help, individual counseling services and family therapy so you can learn how to support your child in a healthy way. In treatment, people who self-injure learn tools to change their negative self-perceptions and improve their self-worth, which lessens the need for relief through self-injury. They also learn that self-injury is not shameful \u2013 it\u2019s a way of dealing with pain and distress at a time when they don\u2019t have other ways of coping. Talking about it clears the way for learning new coping skills and moving forward.