When the First Thing They Say Is, "Please Don’t Hospitalize Me"

When the First Thing They Say Is, "Please Don’t Hospitalize Me" A reflection on self-harm, harm reduction, and decolonizing our therapeutic responses

This year has been heavy. So many people are carrying the weight of grief, loss, pain, trauma—and for many, the burden has become so overwhelming that they turn to self-harm or find themselves navigating thoughts of suicide.

As a therapist, I’ve noticed a significant rise in self-harming behaviors among my clients. And more often than not, the first thing they tell me is: “Please don’t send me to the hospital.”

Sometimes, we share a soft laugh in that moment—not because it’s funny, but because it’s human. It’s a nervous, weary laugh that speaks volumes. It’s a small act of resistance and an expression of how deeply wounded our communities have been by punitive systems posing as care.

Please don’t get me wrong: self-harm is serious, and it absolutely requires compassionate, immediate attention. But as therapists, especially those of us who are committed to decolonial practice and culturally responsive care, we must also reflect on how the systems we've been trained in often fail the very people we’re here to support.

Harm Reduction as a Healing Practice

One of the most powerful tools I’ve embraced in my work is harm reduction. Rooted in compassion and autonomy, harm reduction is not just a public health strategy—it’s a philosophy that meets people where they are, rather than where we think they should be.

Harm reduction honors the truth that healing is not linear, and that people don’t need to be “perfectly well” to deserve support, safety, or community. It acknowledges that behaviors like self-harm often serve a purpose—relief, regulation, expression—even if they're not sustainable. Rather than criminalize or pathologize those behaviors, harm reduction invites us to understand them, explore alternatives, and move toward change at a pace that feels possible.

For my clients, harm reduction has meant small steps: replacing tools with softer ones, journaling before urges take over, naming the emotion instead of acting on it, sitting with a feeling for 30 seconds longer than the week before. These steps matter. They are acts of resistance. They are progress.

What If the Default Isn’t Hospitalization?

If our first reaction to a client's disclosure of self-harm is hospitalization, it’s worth asking ourselves: Why?

Yes, safety matters. But so does context. For BIPOC clients, hospitalization is rarely neutral. It can be retraumatizing, stigmatizing, and at times outright violent. It often removes people from their support systems, enforces medical authority, and reinforces shame.

Clients don't need to be punished for being in pain. They need to be heard. They need to be seen. They need to be trusted.

And we, as therapists, need to do the inner work:

• What’s your relationship to risk?

• What are your legal vs. ethical responsibilities—and where is there room for humanity?

• Are you able to sit with discomfort?

• Have you been trained in alternatives to hospitalization?

• Can you hold someone’s pain without needing to control it?

A More Liberatory Approach to Self-Harm

Here are a few ways we can support clients navigating self-harm through a harm-reduction, decolonial lens:

• Ask, don’t assume: “What does self-harm do for you? How does it help?”

• Name the purpose: Validate the survival logic, not just the symptom.

• Co-create safety plans: Include the client in developing real, practical strategies that reflect their reality.

• Check your bias: Notice your own discomfort or urges to fix, rescue, or control.

• Offer alternatives: Emotional regulation tools, somatic practices, grounding exercises, journaling prompts, or expressive arts.

• Build community: Help clients identify safe people to reach out to—peers, support groups, mentors, cultural healers.

Self-harm doesn’t mean someone has given up. It often means they’re still trying to feel something, to stay here.

Our work is not to shame, silence, or remove people in pain. Our work is to stand beside them and say: I’m here. You’re not alone. There is another way.

Harm reduction is healing.

Harm reduction is hope.

Harm reduction is how we decolonize care.