How to Address Self-Harm in Therapy

Written by Colter Bloxom, LPC

Colter is a licensed psychotherapist and the owner and Executive Director of Thrive Therapy. He specializes in the treatment of anxiety, OCD, identity issues, and more.

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Even if you’re in therapy and there’s trust in that relationship, bringing up the topic of self-harm (nonsuicidal self-injury) can feel overwhelming and scary. You might worry about being judged, about how your therapist will react, or even whether you’ll be forced into treatment (like inpatient or a hospital). You might also experience feelings of guilt or shame around self-harm behavior, which can make it even harder to talk about, even with a therapist.

But self-harm is something that therapists are trained to address, and opening up about it can be the first step toward finding better ways to cope. If you’re struggling with whether or not to talk about self-harm in therapy, or if you’re unsure how to even begin the conversation, this guide will walk you through what to expect, how to bring it up, and how therapy can actually help you with this type of emotional pain.

Can a therapist break confidentiality for self-harm and suicide?

Questions about confidentiality limits is one of the most common concerns people have about bringing up self-harm in therapy, which is completely valid and understandable. The fear of being hospitalized or having your therapist involve someone else in your life can be a huge barrier to opening up.

The truth is that the answer depends on the situation. In most cases, self-harm on its own does not mean your therapist will break confidentiality. For most people, self-harm is different from a suicide attempt, and therapists recognize that many people who self-harm are not suicidal. If your self-harm is non-suicidal and you aren’t at immediate risk of harming yourself in a life-threatening way, your therapist is likely to keep the conversation confidential.

With that said, there are situations where confidentiality could be broken. If your therapist believes that your self-harm is part of a larger suicide risk, or that you’re at immediate risk of serious injury (like accidentally cutting yourself too deeply), they may need to take steps to ensure your safety. This could include involving another healthcare provider, reaching out to a loved one, or, more rarely, initiating involuntary hospitalization.

Confidentiality for suicidal behavior

If you’re actively suicidal or have a plan to end your life, your therapist has a legal and ethical duty to intervene. They (along with any other medical professional) are required to take steps to keep you safe if they have a reasonable suspicion that you might try to end your life.

However, many therapists try to avoid hospitalization unless absolutely necessary. If you’re having suicidal thoughts but don’t want to go to the hospital (and don’t have an active plan to act on them), it’s still worth talking to your therapist. They can work with you to create a safety plan that helps you manage those thoughts without breaking confidentiality.

Either way, in most cases, therapists won’t go behind your back. You shouldn’t need to worry about someone coming in the middle of the night to take you to a hospital because you told your therapist about self-harm at an earlier session. Good therapists will talk to you about their concerns and work with you to come up with a plan that will keep you safe.

How to talk about self-injurious behavior with your therapist

If you’ve never talked about self-harm before, it can be hard to know how to bring it up, even if you’ve talked to your therapist about nearly everything else. You might feel like you need to downplay it or avoid the topic altogether. But being honest with your therapist is the best way to get the support you need.

Here are some tips for talking about self-harm in therapy:

• Be direct and honest. It’s okay if you don’t know how to explain everything, but try to be upfront about what’s going on. You don’t have to share every detail right away—just starting the conversation is enough.
• Let your therapist know what you need. If you’re worried about confidentiality or hospitalization, tell them that upfront. You can say, “I want to talk about something, but I’m scared of what might happen if I do.” Most therapists will appreciate your honesty and help guide the conversation in a way that feels safe for you.
• Talk about what self-harm does for you. People self-harm for different reasons—it might be a way to cope with overwhelming emotions, numbness, or distress. Understanding your triggers can help your therapist support you more effectively.
• Discuss alternative coping strategies. If you’re not ready to stop self-harming, that’s okay. Recovery isn’t an all-or-nothing process. Your therapist can help you come up with alternatives that feel manageable, even if quitting completely doesn’t feel possible right now.
• Know that therapy takes time. You won’t have to “fix” everything in one session. Healing from self-harm is a process, and therapy is about finding healthier ways to cope over time.

What’s the best treatment for self-harm? Best way to cope

There isn’t one single treatment for self-harm, but therapy is one of the most effective ways to address it. Some of the most evidence-based approaches include:

• Cognitive-behavioral therapy (CBT): Helps identify and change the thought patterns that contribute to self-harm.
• Dialectical behavior therapy (DBT): Teaches emotional regulation and distress tolerance skills, which can help reduce the urge to self-harm.
• Trauma-informed therapy: If self-harm is linked to past trauma, working through those experiences in therapy can help.

Self-harm can feel like the only way to cope, but with time and support, it’s also possible to develop other strategies that help you manage emotions without hurting yourself.

Instead of self-harming to cope with painful or overwhelming emotions, try:

• Reaching out to loved ones
• Listening to loud music
• Eating spicy food
• Rubbing an ice cube over where you want to hurt yourself
• Writing or drawing on your arms

IOP for self-injury in Phoenix

If you’re struggling with self-harm and feel like once-a-week therapy isn’t enough, an intensive outpatient program (IOP) might be a good option for you. A mental health IOP has many benefits, including providing structured support multiple times a week, which can be especially helpful if you’re dealing with severe emotional distress that’s leading to self-harm.

At Thrive Therapy, our IOP in Phoenix is designed specifically for mental health (not just addiction treatment like many other programs). Our program meets three times a week (for a total of 9 hours per week), and combines evidence-based approaches like CBT, DBT, and skills training to help you build healthier coping mechanisms for mental health concerns like self-ham. 

If you’re interested in learning more about our IOP for self-harm, reach out for a free consultation. You don’t have to go through this alone. Thrive has got your back.