When a whistleblower claimed that the charity LGBT Youth Scotland had advised teenagers to use sterilized blades if they were self-harming, the reaction was a mix of horror and disbelief. How can a youth advocacy organization condone such behavior under the guise of safeguarding? And, more disturbingly, has this sort of advice become common practice?

Self-harm among adolescents and young adults is one of the defining mental health challenges of our time. Between April 2022 and March 2023, there were 73,239 emergency hospital admissions for intentional self-harm in England, equating to a rate of 126.3 per 100,000 people. While the numbers are widely reported, less scrutiny is given to how professionals should respond. Harm-minimization strategies, which were once a last resort, are now sliding into the mainstream. With them comes a moral dilemma: when does seeking to reduce harm morph into enabling behavior?

To some, harm minimization is common-sense pragmatism. It accepts that stopping self-harm may not be realistic in the short term, so instead encourages safer behaviors while deeper therapeutic work begins. This might mean holding ice cubes, snapping rubber bands, or punching pillows. More controversially, it can involve guidance on how to self-harm “safely”: use clean blades, avoid arteries, treat wounds. To others, though, it sounds like a dangerous normalization of self-mutilation.

For clinicians, the therapeutic relationship requires careful handling. Push too hard, and the client may withdraw or begin concealing the truth. Too lenient, and the clinician risks collusion: a subtle complicity that reinforces the very behavior they are meant to challenge. The key distinction is this: supportive behavior promotes positive growth, while enabling behavior permits harm to continue under the guise of care.

Understanding why young people self-harm is essential. For some, it offers a way to feel something in the midst of emotional numbness; for others, it’s a method of externalizing psychological pain. One client once told me she came to dinner with bloodied arms because it was the only way she could communicate her distress to her mother. The act may bring a brief sense of calm, but it’s short-lived, often followed by shame, isolation and the return of the original pain, now compounded.

This is why harm-minimization must remain a short-term measure, embedded within a broader, clearly defined therapeutic strategy. Underlying causes must still be addressed. Without that deeper work, the behavior will inevitably resurface. But when do harm-minimization advocates shift from tolerance to normalization? Teaching minors how to self-harm “safely” risks embedding the behavior into their identity. It sends a bleak, nihilistic message: this is how you cope.

This isn’t how psychotherapy used to work. Traditionally, therapy was structured and challenging — a process of reflection, exploration, and change. But in recent years, it has been rebranded as “emotional support”: softer, more validating, and far less transformative. The clinician is no longer seen as a guide through psychological pain, but instead as a comforting presence there to reassure rather than to challenge.

But that isn’t the role of the clinician. The Samaritans offer emotional support, and their work is vital. Clinicians offer something else: a structured path through distress, toward understanding and change.

It’s no coincidence that a similar pattern is playing out in the context of gender identity. In the rush to soothe, professionals bypass the deeper sources of distress. Rather than exploring what lies beneath a young person’s discomfort, they are encouraged to affirm it, swiftly and unquestioningly. Where harm minimization risks entrenching maladaptive behaviors, affirmation becomes a shortcut that avoids psychological inquiry altogether. What begins as compassion can harden into ideology.

Humans crave grand solutions. A ceremonial act of self-harm can feel oddly satisfying, conclusive and meaningful. By contrast, the mundane habits of recovery such as sleep, exercise, and connection can seem trivial and unconvincing. But that’s where the real work lies. Therapy ought not to sanctify, validate or even fetishize pain. After all, compassion without clarity isn’t kindness: it’s confusion.

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Stella O’Malley is a psychotherapist and bestselling author. She is Founder-Director of Genspect, an international organisation that advocates for a healthy approach to sex and gender.

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