Self-Harm and Suicidality in Complex Trauma: Understanding the Logic Behind the Pain
Suicidal thoughts and self-harm are issues that frequently accompany complex trauma. Unfortunately, many therapists feel ill-equipped to meet the needs of individuals struggling with these experiences. Understandably, suicidality and self-harm evoke a great deal of anxiety in therapists—myself included.
My perspective shifted when I encountered Janina Fisher’s work on suicidality and self-harm. She identifies hurting the body or engaging in suicidal thinking as an “ingenious attempt to cope with overwhelming distress and tension” (Fisher, 2023). This framing radically changes the conversation. Rather than seeing these behaviors as evidence of pathology, we can recognize them as survival strategies that arose in the context of childhood abuse and neglect. With that perspective, I found myself better able to support my clients in their therapeutic journeys.
How Do Self-Harm and Suicidality Arise?
Children raised in abusive or neglectful environments must rely on themselves for comfort. Because reaching out for help was unsafe or unavailable, they learned to turn inward. Over time, coping strategies that required no one else emerged: substance use, eating disorders, self-harm, high-risk behaviors, or suicidal fantasies.
These behaviors provided reliable ways to soothe unbearable feelings. From a psychobiological perspective, survivors of repeated trauma often discover that:
Adrenaline is calming
Dissociation is calming
Pain can stimulate endorphins, creating an analgesic effect
In other words, self-harm and suicidal ideation bring a measure of relief that depends entirely on the self—no one else is needed.
Why Self-Harm “Makes Sense”
To many outsiders, self-harm looks irrational or destructive. But when we understand its function, it becomes clear why it persists:
It relieves unbearable distress in the moment.
It offers a sense of control, especially when connection with others feels unsafe.
It can even feel like a “friend”—a strategy that has always been available when nothing else was.
Unfortunately, relief is usually short-lived. Shame and secrecy quickly follow, leaving the survivor feeling defective, repulsive, or “crazy.” And because these behaviors echo the secrecy of the original abuse, attempts to discuss alternatives often heighten shame unless framed with validation and respect.
The Therapist’s Role: From Pitfalls to Healing
Therapists often fall into common pitfalls when working with self-harm and suicidality:
Interpreting self-harm as masochism or a cry for help, rather than relief-seeking
Underestimating the role of neglect in limiting coping resources
Assuming the body has inherent value, when survivors often experience it as worthless or disgusting
Becoming locked in power struggles over “safety” rather than supporting the patient’s own inner conflict
Instead, we can create therapeutic victories by shifting our approach:
Ask about feelings before the act: “What were you feeling when the urge came?”
Explore the coping repertoire: “What else did you try before turning to self-harm?”
Understand the relief: “How did self-harm help you feel better, and how long did the relief last?”
Validate the ingenuity: Recognize self-harm as a resourceful, if costly, way of surviving.
This stance reframes suicidal ideation as a kind of “bail-out plan”—a survival strategy, not simply a wish to die. By honoring the protective function, we build credibility to talk about the costs of self-harm and to explore safer alternatives.
Pathways Toward Healing
The ultimate goals are twofold:
Creating safety in the present
Finding safe ways to “take the edge off the pain”
We cannot promise complete relief, but we can help patients reduce the intensity of their distress in ways that do not perpetuate the cycle of shame and secrecy. Over time, survivors can also learn to treat their bodies with respect, even if they do not yet believe they are worthy of it.
By allying with patients in their dilemma—struggling with them rather than against them—we create a therapeutic space where self-harm can be understood, honored as resourceful, and gradually replaced with healthier, more sustainable strategies for relief.
✨ If you work with trauma survivors, remember: self-harm and suicidality are not signs of weakness or failure—they are survival strategies. And when we as therapists meet them with respect, curiosity, and compassion, we can help transform those survival strategies into pathways for healing.