Self-harm and substance use can be hidden, even from family members living in the same home. Both carry stigma, which can make asking for help harder. The combination is clinically recognised, and integrated treatment can address both behaviours and the distress behind them.
What we mean by self-harm
Self-harm, sometimes called non-suicidal self-injury (NSSI), refers to deliberate damage to one’s own body without suicidal intent.
It is important to distinguish self-harm in this sense from suicidal behaviour. The two can overlap (people who self-harm have elevated risk of later suicidal behaviour) but they are typically different in intent. Most self-harm is not an attempt to end life. It is something else, often a way to manage unbearable internal experience, even though the behaviour itself causes harm.
That said, the elevated suicide risk is real, and treatment plans take both possibilities seriously.
Why people self-harm: A function-based view
Modern clinical understanding sees self-harm as a behaviour with functions. The function is what the behaviour is doing for the person, regardless of how distressing it appears from outside. Common functions include:
Emotional regulation
Self-harm often produces relief from overwhelming emotional states. The pain interrupts emotion, and an endorphin response calms the system. The relief is short term and does not make the behaviour safe. It should be understood as distress requiring care, rather than dismissed as “attention seeking”.
Self-punishment
Some people self-harm in response to a felt sense of badness, shame, or guilt. The injury functions as punishment.
Re-establishing sensation
People who experience dissociation (a sense of disconnection from self or reality) may self-harm to feel real again, to break through the numbness.
Communication
Less commonly than stigma suggests, self-harm can communicate distress to others when words cannot. This is not “attention seeking” in any trivial sense; it is signalling a level of distress that the person cannot voice.
Control
In situations of helplessness or chaos, self-harm can provide a sense of agency. The body is the one thing under the person’s control.
These functions overlap with the functions of substance use. Substances also regulate emotion, also punish, also break through numbness, also provide control. Which is why the two often co-occur.
How self-harm and substance use are linked
Shared drivers
Both behaviours often emerge in response to overwhelming emotion, trauma history, identity struggles, depression, anxiety, BPD, eating disorders, or relational distress. The underlying conditions overlap heavily.
Functional substitution
A person who self-harms may use substances to suppress the urge to harm. A person who uses substances may turn to self-harm when substances are unavailable or insufficient. The two behaviours can move in and out of each other.
Compound vulnerability
Both intoxication and withdrawal increase the risk of self-harm. Reduced inhibition, increased emotional reactivity, and reduced impulse control during intoxication can lower the barrier to acting on urges.
Shared treatment needs
Both behaviours respond to similar therapeutic approaches: skills for emotional regulation, distress tolerance, identity work, and trauma processing where indicated. Treatment that addresses both rather than one improves outcomes.
The specific clinical risks of the combination
Increased suicide risk
The combination of self-harm and substance use significantly elevates suicide risk above either alone. This is one of the most important reasons specialist clinical attention matters.
Acute safety
Substance-impaired self-harm can produce more severe injuries than the person intended. Combined intoxication and self-harm in isolation (e.g. at home alone at night) is particularly high risk.
Reduced wound care
People may neglect wound care while intoxicated. Infection and complications follow.
Co-occurring conditions
The combination is often a marker of significant underlying conditions: severe trauma, BPD, severe depression. Treating only the surface behaviours, without addressing what lies beneath, leaves the underlying picture untreated.
What effective treatment looks like
Safety first
Acute risk is assessed and managed on admission. This includes evaluation of suicidality, current means of self-harm available, severity of recent episodes, and the immediate environment.
Comprehensive assessment
Beyond the immediate behaviours, the assessment looks at:
- Substance use history and current pattern.
- Self-harm history, including age of onset, frequency, severity and triggers.
- Mental health history including depression, anxiety, BPD features, eating disorder features.
- Trauma history.
- Family history.
- Medical assessment of any injuries or complications.
- Current support and risk environment.
Detox with specific attention to risk
Substance withdrawal often worsens emotional state and increases self-harm risk. Detox is managed with clinical care, including monitoring of self-harm urges and additional support during the most volatile periods.
Skill-building therapy
DBT-informed work is the strongest evidence base for self-harm. The four DBT skill modules (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness) directly target the function of self-harm and addiction.
A specific DBT skill, the TIPP skill (Temperature, Intense exercise, Paced breathing, Paired muscle relaxation), is often taught in early treatment as an immediate alternative to acting on urges. Other distress tolerance skills follow.
Trauma-focused work when appropriate
For many people in this combination, trauma is part of the picture. EMDR, trauma-focused CBT, and related approaches are integrated once stability supports the work.
Identity work
Self-harm and substance use both often become part of identity. The recovery work includes the gradual building of a self that is not defined by these behaviours.
Family and partner inclusion
With consent, family or partner involvement supports the work. Family members benefit significantly from learning how to respond, what is helpful, and what is not.
Aftercare with continuity
The 12-month aftercare programme at Anker Huis provides the continuity that this combination requires. Skill maintenance, ongoing support, and rapid re-engagement if relapse occurs are the structure.
What helps and what does not from family
If your loved one is in this combination, the responses that help and the responses that backfire are not always intuitive.
Helps
- Validating the underlying emotional experience without endorsing the behaviour. “I can see how much pain you are in. I want to help you find ways through it that do not hurt you more.”
- Calm presence in crisis. Panic from family escalates the person’s panic.
- Clear, consistent limits held with care, not punishment.
- Practical safety measures in the home: limited access to means, agreed plans for what to do when urges are intense.
- Your own support. Family members in this situation are often deeply exhausted. Get help for yourself.
- Encouraging professional support without demanding immediate change.
Does not help
- Shaming or punishing responses to self-harm. These reliably worsen the behaviour.
- Catastrophising. Treating every episode as a crisis can produce a destabilising emotional environment.
- Ignoring. Pretending it is not happening leaves the person isolated.
- Demanding commitments not to self-harm again. People in active self-harm often cannot promise this, and the broken promise feeds shame.
- Replacing all the person’s coping strategies at once. Self-harm has a function. Until alternative ways of meeting the function are in place, removing the behaviour alone is not enough.
When the person is not ready for treatment
Some people in this combination are not yet ready to engage with clinical treatment. Family members can still:
- Make sure crisis resources are known and accessible.
- Reduce access to means of severe self-harm where possible.
- Maintain connection and care without enabling.
- Get their own clinical support.
- Keep supportive structure in place while encouraging engagement.
The change is theirs to make. Your steady, supportive presence is part of the conditions that can make movement possible.
FAQ: self-harm and substance use
Is self-harm the same as a suicide attempt? Usually no. Most self-harm is not aimed at ending life. It is, however, a sign of significant distress and is associated with elevated long-term suicide risk.
Can someone recover from both self-harm and substance use? Yes. With appropriate integrated treatment, most people improve significantly. Recovery is possible.
How can I make the home safer? Reasonable safety measures are appropriate. Total environmental control rarely works. The deeper work is in equipping the person with alternative skills.
Does Anker Huis treat clients who self-harm? Yes. Self-harm with co-occurring substance use is within our clinical scope. Severe acute self-harm risk may require psychiatric stabilisation before residential admission.
Is self-harm only an issue in adolescents? No. It is more often visible in adolescents but is present across age groups, often hidden in adults.
What about the scars? Visible scars often carry their own ongoing pain. Therapy can address the relationship to the body and to the scars, separately from the immediate behaviour.
If self-harm and substance use are present together, Anker Huis provides specialist integrated treatment in Cape Town. Call +27 72 088 0446 or email info@ankerhuis.co.za for a confidential conversation. If you are in immediate crisis, contact SADAG on 0800 567 567 or emergency services.
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