Marc Ferrer, psychiatrist: ‘With teenagers, repeated self-injury greatly increases the risk of becoming suicidal’

The charismatic Lieutenant Columbo – the main character of the homonymous television show from the 1960s – used to solve crimes thanks to his boundless curiosity. By asking endless questions (with a touch of naivety and cluelessness, more often than not) he always arrived at the truth. That is precisely the tactic that Spanish psychiatrist Marc Ferrer applies to study his patients: teenagers who are often admitted to his hospital when their mental health problems worsen or after an attempted suicide. “When in doubt, with a teenager, don’t think that they want to die and are depressed, and don’t think that they are manipulating you: just show curiosity,” he recommends.

Ferrer is the head of hospitalization of the psychiatry service at the Vall d’Hebron hospital in Barcelona, which recently opened an admission unit for pediatric patients. Every day, he witnesses from the front lines the rise of mental health problems suffered by young people. He explains that, although the pandemic intensified this upward trend of self-harm and suicide attempts, this phenomenon was already underway before that. The psychiatrist participated in a study carried out at his hospital in which they found that, between 2015 and 2017, self-harm represented 20.4% of admissions treated in pediatric psychiatric emergencies; between 2017 and 2021, that figure had risen to 70%; and today admissions for this cause are approximately 75%, according to the institution.

Question. What is happening?

Answer. We have to be prudent. This is a phenomenon that worries us due to the recklessness of teens and the romanticization of suicide, but there is a series of nuances behind it: we see people that manifest the emotional overflow or the 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 happens? In some cases these behaviors are addictive. It’s a quick way to end emotional discomfort. Learning to manage emotional discomfort is a part of life, of the maturation process. Teenagers find it difficult to live with a negative emotion and look for ways to quickly relieve it.

Q. But what changed in recent years? Because this difficulty to manage emotional discomfort at this stage of life has always existed.

A. Now everything goes faster. There is less time to go through this process of sitting down to analyze, talk, learn to relativize... and this speed in life is closely linked to social media, to the internet, to the whole evolution that our society is experiencing. We have to smarten up and adapt to these changes, because kids are really having a hard time: evidently, the internet and social media can provide them with a positive reinforcement because you post a photo, you get a like, and with that everyone experiences a feeling of pleasure – even more so if it’s a teenager. However, when you receive a negative comment or don’t get as many likes as you think you should, the negative emotion that the teenager experiences is much more intense, and they are not as capable of managing this frustration. These are the new variables that our teenagers are experiencing, in addition to the usual ones, such as having a disagreement with your peers, being criticized, being picked on or being bullied.

Q. Is social media the main risk factor for emotional distress in adolescents?

A. 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 media, the solution is not to take away the teenager’s phone – because when you do these things, what you do is increase the frustration even more, because you’re isolating them. There are studies that show that isolation is the most dangerous form of bullying. Therefore, if you take their phone, unwittingly, what you are doing can be counterproductive.

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

A. I talk about being creative because certain opinion makers want a quick fix, saying that we have to take their phones away or change society. The society in which we live in is what it is, flaws and all, and we do have to improve the situation, but realistically. Prevention has to be carried out in schools, which is where most of the problems are detected; but perhaps we shouldn’t put all the burden on the teachers, who already have a lot on their plate. Health-wise, we probably have to intervene more in health centers and carry out emotional education programs.

Q. You said that self-harm is used as a mechanism to alleviate emotional discomfort. What is the difference between that and suicide attempts?

A. There are self-harming behaviors that don’t seek suicide; they seek other things. Most of them seek to alleviate the emotional discomfort, the mental blockage and the feeling of overwhelm that an adolescent may experience. Biologically, a teenager is less capable of stopping, thinking, relativizing and organizing; that is, what we call the executive function, which is centered in the prefrontal cortex and is the last thing to mature (it becomes fully mature at 24 or 25 years of age). Thus, we are faced with a person who, if subjected to many stressors, finds it much more difficult to deal with them and freezes more easily.

Over the years, alternatives to quickly end emotional discomfort have been arising. Drugs appeared, which are being consumed at increasingly young ages. There are kids who at 12 or 13 are smoking joints, which is another way to quickly end this emotional discomfort. And within the range of options, self-harm has emerged in recent years: many kids tell us that they started to harm themselves because a classmate did it, or they saw it on social media; and there are kids who don’t experience anything but pain when they do it, but others feel pleasure, relief, and it is an effective measure for them. However, scientific evidence tells us that when they begin this pattern of repeated self-injury, the risk of them becoming suicidal injuries greatly increases.

Q. It is a gateway to suicide, then.

A. Right. You see that you’re losing control, that your family finds out and, usually, the family doesn’t have the capacity to understand this behavior and experiences it as a wake-up call. This makes you feel worse for doing it. There can be a paradoxical effect: I use it because they are bullying me and I feel marginalized, but they end up marginalizing me even more because they see me as weird; that’s how suicide ends up entering the equation.

Q. How true is the notion that they do it to draw attention?

A. There is such a high heterogeneity in this type of behavior... I suppose there will be some cases that do use it to attract attention. Our patients often do it to get attention or to communicate that they are emotionally overwhelmed. But when they say “to draw attention,” they do it with contempt; it’s as if you’re telling them that they are a fraud, and that is the mistake.

Q. When in doubt, how should people respond to these situations?

A. I have been visiting teenagers for quite a few years and I have learned one thing: you don’t know anything. And this is what you have to communicate to the teenager, that you have no idea what they’re going through and that you are really curious for them to tell you. Some therapists talk about the Columbo attitude [the apparently absent-minded detective from the television show], because by showing curiosity and acting like you know knowing, you end up knowing everything. When in doubt, with a teenager, don’t think that they want to die and are depressed, and don’t think that they are manipulating you: show curiosity.

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

A. In adolescence, it’s tremendous. 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 be like the influencers, the 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 put their health at risk, such as the blue whale game?

A. We try not to be alarmists and to evaluate 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.

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

A. It’s this romantic thing about death and life, which is basically linked to relational stress. In this relational stress, great sadness appears, and then comes the flirtation with death. But there is no clear awareness. An adult has a brain that is more mature overall and can assimilate the concept of life and death much better. Clearly, when a teenager reaches 16 or 17 years of age, they already have more capacity, but brain maturation does not end until age 25. The life-death concept that they have is not the same as ours.

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

A. In adolescence, both situations occur. A 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, teenagers have an emotional instability and impulsivity that makes them especially at risk for this type of situation. And, by harming themselves, at some point they go from being non-suicidal to being suicidal, as a result of the situation becoming more complicated.

Q. What role did the pandemic actually play in the rise of self-harming behavior and poor adolescent mental health?

A. I am convinced that this phenomenon was already underway before. The pandemic was a major stressor; however, 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 drastic methods, but in the case of adolescents, they are at 50%. Why?

A. Because suicidal behavior in adolescence is different from that of adults; it is much more linked to impulsivity, and impulsivity equals unpredictability.

Q. How do socioeconomic variables influence poor mental health?

A. They are key. These behaviors can appear in upper or lower class; the question is how the environment responds. There is some advice that can help: when you see this, validate it. Don’t judge them, listen to them, give them time, talk. If this is not possible, if the family is broken or if there is an abusive parent, a corrective response cannot be expected. Instead, the situation often gets worse.

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