Marc Ferrer, psychiatrist: “In adolescents, repeated self-harm greatly increases the risk of them becoming suicidal” | Health & Wellness

The charismatic detective Colombo, protagonist of a television series of the same name in the sixties, used to solve crimes showing boundless curiosity. With questions and more questions, often covered in a veneer of naivety and cluelessness, he always ended up getting to the truth. And, precisely, psychiatrist Marc Ferrer (Girona, 48 years old) still appeals to this peculiar attitude today to study his patients: adolescents who are often admitted to his hospital after an exacerbation of their mental health problems or after a suicide attempt. “When in doubt, with a teenager, don’t even think that he wants to die and is depressed, or think that he is manipulating you: be curious,” he recommends.

Ferrer is the head of hospitalization of the psychiatry service at the Vall d’Hebron hospital in Barcelona, ​​which has recently opened an admission unit for pediatric patients. He lives every day, from the front line, the rise of mental health problems suffered by the youngest people and warns that, although the pandemic encouraged this upward curve of self-harm and suicide attempts, this phenomenon had already been brewing before. The psychiatrist participated in a study at his hospital in which they found that, between 2015 and 2017, self-harm represented 20.4% of admissions treated in pediatric psychiatry emergencies; Between 2017 and 2021, that figure had already risen to 70% and now, admissions for this cause are around 75%, according to the health center itself.

Ask. What’s going on?

Answer. We have to be cautious. It is a phenomenon that worries us due to the unconsciousness of the adolescent and that more romantic thing of suicide, but behind it there are a series of nuances: we see that there are boys who manifest the emotional overflow or emotional blockage typical of adolescence, with aggressive behaviors, with self-harm or suicide attempts, understanding that it is an effective method to alleviate emotional discomfort. What’s going on? That in some cases these behaviors are addictive, that is, it is a quick way to end emotional discomfort. Learning to manage emotional discomfort is part of life, of the maturation process. Teenagers find it difficult to live with negative emotion and look for ways to quickly relieve it.

Q. But what has changed in recent years? Because this complexity to manage emotional discomfort at these ages has always existed.

R. Now everything goes faster. There is less time to do this process of sitting down to analyze, talk, learn to relativize… And this speed in life is closely linked to social networks, to the Internet, to all the evolution that our society is experiencing. We have to be alert to adapt to these changes because kids really have a hard time: obviously, the Internet and networks can provide them with a positive stimulus because you post a photo, you have a like and with that everyone experiences a feeling of pleasure and the adolescent, even more so. However, when you receive negative feedback or do not have the likes that you think you should have, the negative emotion that the adolescent experiences is much more intense and with less capacity to manage this frustration. These are the new variables that our adolescence is experiencing, in addition to the usual ones, such as having a disagreement with your equal, being criticized, being picked on, or being hurt. bullying.

Q. Are social networks the main risk factor for emotional distress in adolescents?

R. It is one of the main ones and the one that forces us to be more creative. Because the solution is not to cut off social networks, the solution is not to take away the teenager’s cell phone, because when you do these things, what you do is increase the frustration even more because you isolate them. There are studies that indicate that isolation is the most dangerous of the bullying. Therefore, if you remove your cell phone, unconsciously, what you are doing can be more counterproductive.

Q. And what can be done, then, to stop these toxic situations?

R. I say this about being creative because of certain opinion leaders who cut corners, saying that we have to get rid of our cell phones or change society. The society we live in is what it is, with its flaws, and we have to improve the situation, but in a realistic way. Prevention has to be done in schools, which is where most of the problems are detected; but perhaps not put it all on the teachers, who already have many demands. It is likely that from a health perspective we will have to intervene more in the centers and carry out emotional education programs.

Over the years, options have been incorporated to quickly end emotional discomfort. Drugs appeared first and in recent years self-harm has appeared

Q. It said that self-harm is used as a mechanism to alleviate emotional discomfort, what difference is there with suicide attempts?

R. There are self-harming behaviors that do not seek suicide, but rather other things. Most of them seek to alleviate the emotional discomfort, mental blockage and feeling of overwhelm that the adolescent may experience. Biologically, an adolescent has less capacity to stop, think, relativize and organize; that is, what we call the executive function, which is centered in the prefrontal cortex and which is the last thing to mature (it just matures at 24 or 25 years old). Therefore, we are faced with a person who, if you subject them to many stressors, finds it much more difficult to manage them and becomes blocked more easily.

Over the years, options have been incorporated to quickly end emotional discomfort. Drugs appeared, increasingly consumed at younger ages and there are children who at 12 or 13 years old are smoking joints, which is also a way to quickly end this emotional discomfort. And within the catalog of options, self-harm has appeared in recent years: many kids tell us that they started to self-harm because a classmate did it or they had seen it on their networks; and there are kids who don’t experience anything with it, only pain, and others who feel pleasure, relief, and find it effective as a measure. But scientific evidence tells us that when they begin this pattern of repeated self-injury, the risk of them ending up as suicidal self-injury greatly increases.

Q. It’s a gateway to suicide, then.

R. Correct. You see that you are losing control, that your family finds out and, normally, the family does not have the capacity to understand this behavior and experiences it as a wake-up call. Which makes you feel worse for doing it. This paradoxical effect can occur: I use it because they are making me bullying and I feel marginalized, but they end up marginalizing me even more because they see me as strange; and that’s how suicide ends up appearing.

Q. What is true in this idea that they do it to get attention?

R. In this type of behavior there is such a high heterogeneity… I suppose there will be some cases that use it to attract attention. Our patients often do it to get attention or to communicate that they are emotionally overwhelmed. But when it is called attention-grabbing, it is done in a derogatory way: it is as if you are telling him that he is a fake, and this is the mistake.

Non-suicidal self-injurious behaviors in adolescents seek to alleviate emotional discomfort and the feeling of being overwhelmed.

Q. When in doubt, what should be the response to these situations?

R. I have been visiting teenagers for quite a few years and I have learned one thing: that you know nothing. And what you have to communicate to the teenager is this, that you have no idea what is happening to him and that you are too curious for him to tell you. Some therapists talk about the Columbo attitude (the detective from the television series, who seemed to know nothing), because by showing curiosity and the attitude of not knowing, you end up knowing everything. When in doubt, with a teenager, neither think that he wants to die and is depressed, nor think that he is manipulating you: show curiosity.

Q. What is the weight of fashions and the imitation effect on these behaviors?

R. In adolescence, very big. When you are growing up, there is an identity crisis and the need to find yourself is more marked. And it is very common for kids to do things to look like influencers, YouTubers… At these ages one tends to be gregarious and the imitation effect is present in all of these phenomena.

Q. Are you worried about these viral challenges that endanger health, like the blue whale game?

R. We try not to be alarmist and to calibrate these phenomena well because, sometimes, they appear and disappear with astonishing speed. What concerns us most is that we have to be very close to them to be aware.

“Suicidal behavior in adolescents is linked to impulsivity and this is equal to unpredictability”

Q. Is the concept of death trivialized at these ages?

R. It’s that romantic thing about death and life, basically tied to relational stress. In this relational stress, great sadness appears and then the flirtation with death is incorporated. But there is no clear conscience. An adult has a brain, in general, more mature and can integrate the concept of life and death much better. Obviously, when a teenager reaches 16 or 17 years old, he already has more capacity, but brain maturation does not end until he is 25. The life-death concept that they have is not the same that we can have.

Q. What happens to make that leap towards a suicide attempt? Is there always an underlying pathology or is impulsivity the great enemy?

R. In adolescence, there are both situations. Psychopathology as such, that is, the disorder, which would be a bipolar disorder, schizophrenia, a depressive disorder… If you have a psychosis, you are disconnected from reality; In depression, you are not disconnected, but there is a distortion of reality, you see things worse than they really are. And then, apart from this, in adolescents there is an emotional instability and impulsivity that makes them especially at risk for this type of situation. And, by doing self-harm, at some point, they go from being non-suicidal to being suicidal, as a result of the situation becoming more complicated.

Q. What role has the pandemic really played in the rise of self-harming behavior and poor adolescent mental health?

R. I am convinced that this was a phenomenon that was already going on. The pandemic was a major stressor, but, in our study, the rise of the curve is independent of the variables related to the pandemic.

Q. In adults, more men than women die by suicide because they use more forceful methods. But in the case of adolescents, they are at 50%. Because?

R. Because suicidal behavior in adolescence is different from that of adults and is much more linked to impulsivity. And impulsiveness equals unpredictability.

Q. How do socioeconomic variables influence poor mental health?

R. They are key. These behaviors can appear in upper or lower class, the question is how the environment responds. There are a number of tips: when you see this, validate it; Don’t judge him, listen to him, give him time, talk. If this cannot be done, if the family is broken or if there is an abusive parent, a corrective response cannot be expected. Instead, many times there is a worsening of the situation.

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