Self-injury is a type of abnormal behavior and usually accompanies a variety of mental health disorders, such as depression or borderline personality disorder.

• General Information About Self-Injury
• Conditions in Which Self-injurious Behavior is Seen
• Borderline Personality Disorder
• Mood Disorders
• Eating Disorders
• Obsessive-Compulsive Disorder
• Posttraumatic Stress Disorder
• Dissociative Disorders
  • Depersonalization Disorder
  • DDNOS
  • Dissociative Identity Disorder
• Anxiety and/or Panic
• Impulse-control Disorder Not Otherwise Specified
• Self-injury as a psychiatric diagnosis

General Information About Self-Injury

In the DSM-IV, the only diagnoses that mention self-injury as a symptom or criterion for diagnosis are borderline personality disorder, stereotypic movement disorder (associated with autism and mental retardation), and fictitious (faked) disorders in which an attempt to fake physical illness is present (APA, 1995; Fauman, 1994). It also seems to be generally accepted that extreme forms of self-mutilation (amputations, castrations, etc) are possible in psychotic or delusional patients. Reading the DSM, one can easily get the impression that people who self-injure are doing it willfully, in order to fake illness or be dramatic. Another indication of how the therapeutic community views those who harm themselves is seen in the opening sentence of Malon and Berardi's 1987 paper "Hypnosis and Self-Cutters":

Since self-cutters were first reported on in 1960, they have continued to be a prevalent mental health problem. (emphasis added)

To these researchers, self-cutting is not the problem, the self-cutters are.

However, self-injurious behavior is seen in patients with many more diagnoses than the DSM suggests. In interviews, people who engage in repetitive self-injury have reported being diagnosed with depression, bipolar disorder, anorexia nervosa, bulimia nervosa, obsessive-compulsive disorder, posttraumatic stress disorder, many of the dissociative disorders (including depersonalization disorder, dissociative disorder not otherwise specified, and dissociative identity disorder), anxiety and panic disorders, and impulse-control disorder not otherwise specified. In addition, the call for a separate diagnosis for self-injurers is being taken up by many practitioners.

It is beyond the scope of this page to provide definitive information about all of these conditions. I will try, instead, to give a basic description of the disorder, explain when I can how self-injury might fit into the pattern of the disease, and give references to pages where much more information is available. In the case of borderline personality disorder (BPD), I devote considerable space to discussion simply because the label BPD is sometimes automatically applied in cases where self-injury is present, and the negative effects of a BPD misdiagnosis can be extreme.

Conditions in which self-injurious behavior is seen

• Borderline Personality Disorder
• Mood Disorders
• Eating Disorders
• Obsessive-Compulsive Disorder
• Posttraumatic Stress Disorder
• Dissociative Disorders
• Anxiety Disorders and/or Panic Disorder
• Impulse-control Disorder Not Otherwise Specified
• Self-injury as a diagnosis

As mentioned, self-injury is often seen in those with autism or mental retardation; you can find a good discussion of self-harm behaviors in this group of disorders at the website of The Center for the Study of Autism.

Borderline Personality Disorder

"Every time I say something they find hard to hear, they chalk it up to my anger, and never to their own fear."
--Ani DiFranco

Unfortunately, the most popular diagnosis assigned to anyone who self-injures is borderline personality disorder. Patients with this diagnosis are frequently treated as outcasts by psychiatrists; Herman (1992) tells of a psychiatric resident who asked his supervising therapist how to treat borderlines was told, "You refer them." Miller (1994) notes that those diagnosed as borderline are often seen as being responsible for their own pain, more so than patients in any other diagnostic category. BPD diagnoses are sometimes used as a way to "flag" certain patients, to indicate to future caregivers that someone is difficult or a troublemaker. I sometimes used to think of BPD as standing for "Bitch Pissed Doc."

This is not to say that BPD is a fictional illness; I have encountered people who meet the DSM criteria for BPD. They tend to be people in great pain who are struggling to survive however they can, and they often unintentionally cause great pain for those who love them. But I have met many more people who don't meet the criteria but have been given the label because of their self-injury.

Consider, however, the DSM-IV Handbook of Differential Diagnosis (First et al. 1995). In its decision tree for the symptom "self-mutilation," the first decision point is "Motivation is to decrease dysphoria, vent angry feelings, or to reduce feelings of numbness... in association with a pattern of impulsivity and identity disturbance." If this is true, then a practitioner following this manual would have to diagnose someone as BPD purely because they cope with overwhelming feelings by self-injuring.

This is particularly disturbing in light of recent findings (Herpertz, et al., 1997) that only 48% of their sample of self-injurers met the DSM criteria for BPD. When self-injury was excluded as a factor, only 28% of the sample met the criteria.

Similar results were seen in a 1992 study by Rusch, Guastello, and Mason. They examined 89 psychiatric inpatients who had been diagnosed as BPD, and summarized their results statistically.

Different raters examined the patients and the hospital records and indicated the degree to which each of the eight defining BPD symptoms were present. One fascinating note: only 36 of the 89 patients actually met the DSM-IIIR criteria (five of eight symptoms present) for being diagnosed with the disorder. Rusch and colleagues ran a statistical procedure called factor analysis in an effort to discover which symptoms tend to co-occur.

The results are interesting. They found three symptom complexes: the "volatility" factor, which consisted of inappropriate anger, unstable relationships, and impulsive behavior; the "self-destructive/unpredictable" factor, which consisted of self-harm and emotional instability; and the "identity disturbance" factor.

The SDU (self-destructive) factor was present in 82 of the patients, while the volatility was seen in only 25 and the identity disturbance in 21. The authors suggest that either self-mutilation is at the core of BPD or clinicians tend to use self-harm as a sufficient criterion to label a patient BPD. The latter seems more likely, given that fewer than half of the patients studied met the DSM criteria for BPD.

One of the foremost researchers into Borderline Personality Disorder, Marsha Linehan, does believe that it is a valid diagnosis, but in a 1995 article notes: "No diagnosis should be made unless the DSM-IV criteria are strictly applied. . . . the diagnosis of a personality disorder requires the understanding of a person's long-term pattern of functioning." (Linehan, et al. 1995, emphasis added.) That this does not happen is evident in the increasing numbers of teenagers being diagnosed as borderline. Given that the DSM-IV refers to personality disorders as longstanding patterns of behavior usually beginning in early adulthood, one wonders what justification is used for giving a 14-year-old a negative psychiatric label that will stay with her all of her life? Reading Linehan's work has caused some therapists to wonder if perhaps the label "BPD" is too stigmatized and too over-used, and if it might be better to call it what it really is: a disorder of emotional regulation.

If a care giver diagnoses you as BPD and you're fairly certain the label is inaccurate and counterproductive, find another doctor. Wakefield and Underwager (1994) point out that mental health professionals are no less likely to err and no less prone to the cognitive shortcuts we all take than anyone else is:

When many psychotherapists reach a conclusion about a person, not only do they ignore anything that questions or contradicts their conclusions, they actively fabricate and conjure up false statements or erroneous observations to support their conclusion [note that this process can be unconscious] (Arkes and Harkness 1980). When given information by a patient, therapists attend only to that which supports the conclusion they have already reached (Strohmer et al. 1990). . . . The frightening fact about conclusions reached by therapists with respect to patients is that they are made within 30 seconds to two or three minutes of the first contact (Ganton and Dickinson 1969; Meehl 1959; Weber et al. 1993). Once the conclusion is reached, mental health professionals are often impervious to any new information and persist in the label assigned very early in the process on the basis of minimal information, usually an idiosyncratic single cue (Rosenhan 1973) (emphasis added).

[NOTE: My inclusion of a quote from these authors does not constitute a full endorsement of their entire body of work.]

Mood Disorders

Self-injury is seen in patients who suffer from major depressive disorder and from bipolar disorder. It is not exactly clear why this is so, although all three problems have been linked to deficiencies in the amount of serotonin available to the brain. It is important to separate the self-injury from the mood disorder; people who self-injure frequently come to learn that it is a quick and easy way of defusing great physical or psychological tension, and it is possible for the behavior to continue after the depression is resolved. Care should be taken to teach patients alternative ways to cope with distressing feelings and over-stimulation.

Both major depression and bipolar disorder are enormously complex diseases; for a thorough education on depression, go to The Depression Resources List or Depression.com. Another good source of information about depression is the newsgroup alt.support.depression, its FAQ, and the associated web page, Diane Wilson's ASD Resources page.

To find out more about bipolar disorder, try The Pendulum Resource Page, presented by members of one of the first mailing lists created for bipolar people.

Eating Disorders

Self-inflicted violence is often seen in women and girls with anorexia nervosa (a disease in which a person has an obsession with losing weight, dieting, or fasting, and as a distorted body image -- seeing his/her skeletal body as "fat") or bulimia nervosa (an eating disorder marked by binges where large amounts of food are eaten followed by purges, during which the person attempts to remove the food from her/his body by forced vomiting, abuse of laxatives, excessive exercise, etc).

There are many theories as to why SI and eating disorders co-occur so frequently. Cross is quoted in n Favazza (1996) as saying that the two sorts of behavior are attempts to own the body, to perceive it as self (not other), known (not uncharted and unpredictable), and impenetrable (not invaded or controlled from the outside. . . . [T]he metaphorical destruction between body and self collapses [ie, is no longer metaphorical]: thinness is self-sufficiency, bleeding emotional catharsis, bingeing is the assuaging of loneliness, and purging is the moral purification of self. (p.51)

Favazza himself favors the theory that young children identify with food, and thus during the early stages of life, eating could be seen as a consuming of something that is self and thus make the idea of self-mutilation easier to accept. He also notes that children can anger their parents by refusing to eat; this could be a prototype of self-mutilation done to retaliate against abusive adults. In addition, children can please their parents by eating what they are given, and in this Favazza sees the prototype for SI as manipulation.

He does note, though, that self-injury brings about a rapid release from tension, anxiety, racing thoughts, etc. This could be a motivation for an eating-disordered person to hurt him/herself -- shame or frustration at the eating behavior leads to increased tension and arousal and the person cuts or burns or hits to obtain quick relief from these uncomfortable feelings. Also, from having spoken to several people who both have an eating disorder and self-injure, I think it's quite possible that self-injury offers some an alternative to the disordered eating. Instead of fasting or purging, they cut.

There haven't been many laboratory studies probing the link between SI and eating disorders, so all of the above is speculation and conjecture.

Obsessive-Compulsive Disorder

Self-injury among those diagnosed with OCD is considered by many to be limited to compulsive hair-pulling (known as trichotillomania and usually involving eyebrows, eyelashes, and other body hair in addition to head hair) and/or compulsive skin picking/scratching/excoriation. In the DSM-IV, though, trichotillomania is classified as an impulse-control disorder and OCD as an anxiety disorder. Unless the self-injury is part of a compulsive ritual designed to ward off some bad thing that would otherwise happen, it should not be considered a symptom of OCD. The DSM-IV diagnosis of OCD requires:

1. the presence of obsessions (recurrent and persistent thoughts that are not simply worries about everyday matters) and/or compulsions (repetitive behaviors that a person feels a need to perform (counting, checking, washing, ordering, etc) in order to stave off anxiety or disaster);
2. recognition at some point that the obsessions or compulsions are unreasonable;
3. excessive time spent on obsessions or compulsions, reduction of quality of life due to them, or marked distress due to them;
4. the content of the behaviors/thoughts is not confined to that associated with any other Axis I disorder currently present;
5. the behavior/thoughts not being a direct result of medication or other drug use.

The current consensus seems to be that OCD is due to a serotonin imbalance in the brain; SSRI's are the drug of choice for this condition. A 1995 study of self-injury among female OCD patients (Yaryura-Tobias et al.) showed that clomipramine (a tricyclic antidepressant known as Anafranil) reduced the frequency of both compulsive behaviors and of SIB. It is possible that this reduction came about simply because the self-injury was a compulsive behavior with different roots than SIB in non-OCD patients, but the study subjects had much in common with them -- 70 percent of them had been sexually abused as children, they showed the presence of eating disorders, etc. The study strongly suggests, again, that self-injury and the serotonergic system are somehow related.

Posttraumatic Stress Disorder

Posttraumatic stress disorder refers to a collection of symptoms that may occur as a delayed response to a serious trauma (or series of traumas). More information on the concept is available in my quick Trauma/PTSD FAQ. It's not meant to be comprehensive, but just to give an idea of what trauma is and what PTSD is about. Herman (1992) suggests an expansion of the PTSD diagnosis for those who have been continually traumatized over a period of months or years. Based on patterns of history and symptomology in her clients, she created the concept of Complex Post-Traumatic Stress Disorder. CPTSD includes self-injury as a symptom of the disordered affect regulation severely traumatized patients often have (interestingly enough, one of the main reasons people who hurt themselves do so is in order to control seemingly uncontrollable and frightening emotions). This diagnosis, unlike BPD, centers on why patients who self-harm do so, referring to definite traumatic events in the client's past. Although CPTSD is not a one-size-fits-all diagnosis for self-injury any more than BPD is, Herman's book does help those who have a history of repeated severe trauma understand why they have so much trouble regulating and expressing emotion. Cauwels (1992) calls PTSD "BPD's identical cousin." Herman seems to favor a view in which PTSD has been fragmented into three separate diagnoses:

For an incredible amount of information on trauma and its effects, including posttrauma stress syndromes, definitely visit David Baldwin's Trauma Information Pages.

Dissociative Disorders

The dissociative disorders involve problems of consciousness -- amnesia, fragmented consciousness (as seen in DID), and deformation or alteration of consciousness (as in Depersonalization Disorder or Dissociative Disorder Not Otherwise Specified ).

Dissociation refers to a sort of turning off of consciousness. Even psychologically normal people do it all the time -- a classic example is a person who drives to a destination while "zoning out" and arrives not remembering much at all about the drive. Fauman (1994) defines it as "the splitting off of a group of mental processes from conscious awareness." In the dissociative disorders, this splitting off has become extreme and often beyond the patient's control.

Depersonalization Disorder

Depersonalization is a variety of dissociation in which one suddenly feels detached from one's own body, sometimes as if they were observing events from outside themselves. It can be a frightening feeling, and it may be accompanied by a lessening of sensory input -- sounds may be muffled, things may look strange, etc. It feels as if the body is not part of the self, although reality testing remains intact. Some describe depersonalization as feeling dreamlike or mechanical. A diagnosis of depersonalization disorder is made when a client suffers from frequent and severe episodes of depersonalization. Some people react to depersonalization episodes by inflicting physical harm on themselves in an attempt to stop the unreal feelings, hoping that pain will bring them back to awareness. This is a common reason for SI in people who dissociate frequently in other ways.

DDNOS

DDNOS is a diagnosis given to people who show some of the symptoms of other dissociative disorders but do not meet the diagnostic criteria for any of them. A person who felt she had alternate personalities but in whom those personalities were not fully developed or autonomous or who was always the personality in control might be diagnosed DDNOS, as might someone who suffered depersonalization episodes but not of the length and severity required for diagnosis. It can also be a diagnosis given to someone who dissociates frequently without feeling unreal or having alternate personalities. It's basically a way of saying "You have a problem with dissociation that affects your life negatively, but we don't have a name for exactly the sort of dissociation you do." Again, people who have DDNOS often self-injure in an attempt to cause themselves pain and thus end the dissociative episode.

Dissociative Identity Disorder

In DID, a person has at least two personalities who alternate taking full conscious control of the patients behavior, speech, etc. The DSM specifies that the two (or more) personalities must have distinctly different and relatively enduring ways of perceiving, thinking about, and relating to the outside world and to the self, and that at least two of these personalities must alternate control of the patient's actions. DID is somewhat controversial, and some people claim that it is over-diagnosed. Therapists must be extremely careful in diagnosing DID, probing without suggesting and taking care not to mistake undeveloped personality facets for fully-developed separate personalities. Also, some people who feel as if they have "bits" of them that sometimes take over but always while they're consciously aware and able to affect their own actions may run a risk of being misdiagnosed as DID if they also dissociate.

When someone has DID, they may self-injure for any of the reasons other people do. They may have an angry alter who attempts to punish the group by damaging the body or who chooses self-injury as a way of venting his/her anger.

It's extremely important that diagnoses of DID be made only by qualified professionals after lengthy interviews and examinations. For more information on DID, check out Divided Hearts. For reliable information on all aspects of dissociation including DID, the International Society for the Study of Dissociation web site and The Sidran Foundation are good sources.

Kirsti's essay on "bits" and "The Wonderful World of the Midcontinuum" provide reassuring and valuable information about DDNOS, the space between normal daydreaming and being DID.

Anxiety and/or Panic

The DSM groups many disorders under the heading of "Anxiety Disorders." The symptoms and diagnoses of these vary greatly, and sometimes people with them use self-injury as a self-soothing coping mechanism. They've found that it brings fast temporary relief from the incredible tension and arousal that build up as they grow progressively more anxious. For a good selection of writings and links about anxiety, try tAPir (the Anxiety-Panic internet resource).

Impulse-control Disorder

Not Otherwise Specified I include this diagnosis simply because it is becoming a preferred diagnosis for self-injurers among some clinicians. This makes excellent sense when you consider that the defining criteria of any impulse-control disorder are (APA, 1995):

• Failure to resist an impulse, drive, or temptation to perform some act that is harmful to the person or others. There may or may not be conscious resistance to the impulse. The act may or may not be planned.
• An increasing sense of tension or [physiological or psychological] arousal before committing the act.
• An experience of either pleasure, gratification, or release at the time of committing the act. The act . . . is consistent with the immediate conscious wish of the individual. Immediately following the act there may or may not be genuine regret, self-reproach, or guilt.

This describes the cycle of self-injury for many of the people I've talked to.

Self-injury As A Psychiatric Diagnosis

Favazza and Rosenthal, in a 1993 article in Hospital and Community Psychiatry, suggest defining self-injury as a disease and not merely a symptom. They created a diagnostic category called Repetitive Self-Harm Syndrome. This would be an Axis I impulse-control syndrome (similar to OCD), not an Axis II personality disorder. Favazza (1996) pursues this idea further in Bodies Under Siege. Given that it often occurs without any apparent disease and sometimes persists after other symptoms of a particular psychological disorder have subsided, it makes sense to finally recognize that self-injury can and does become a disorder in its own right. Alderman (1997) also advocates recognizing self-inflicted violence as a disease rather than a symptom.

Miller (1994) suggests that many self-harmers suffer from what she calls Trauma Reenactment Syndrome. Miller proposes that women who've been traumatized suffer a sort of internal split of consciousness; when they go into a self-harming episode, their conscious and subconscious minds take on three roles: the abuser (the one who harms), the victim, and the non-protecting bystander. Favazza, Alderman, Herman (1992) and Miller suggest that, contrary to popular therapeutic opinion, there is hope for those who self-injure. Whether self-injury occurs in concert with another disorder or alone, there are effective ways of treating those who harm themselves and helping them find more productive ways of coping.

About the author: Deb Martinson has a B.S. in Psychology, has compiled extension information on self-injury and co-authored a book on self-harm entitled "Because I Hurt." Martinson is the creator of the "Secret Shame" self-injury website.

Source: Secret Shame website

Interview with Bruce Elkin

Bruce Elkin, 55, is a simple living coach and a consultant to individuals, organizations and communities trying to live simple, yet rich lives in harmony with the systems of life that sustain us all. He is the author of the booklet, "Co-Creating Our Common Future" and the forthcoming book, "Living Well, Living Deeply." He is also Director of The Earthways Institute.

Tammie: What drew you to the Environmental movement?

Bruce: In 1973, I was hired by the Calgary Y to develop an environmental Ed curriculum for their new outdoor center. I did a survey of available programs, was disappointed by the either/or approach I found prevalent among those who thought hard science based conceptual understanding was the key and those who thought sensory appreciation and feelings for nature were the key. Then someone gave me a copy of Steve Van Matre's "Acclimatization: A Sensory and Conceptual Approach to Ecological Involvement." I read all SVM's stuff, joined the Institute for Earth Education, eventually became the senior trainer and, that was the start. Later, I developed my own approach incorporating Van Matre's ideas and ideas about personal empowerment, growth and transformation. Over the years, this led me to set up the EW Inst.

Tammie: In examining your own experiences with 'simple living,' what have you found the most significant challenges and rewards to be?

Bruce: The most challenging aspect is how to make a living. I've been living simply most of the time since 1973, trying to keep my income at a "just enough" level. But, figuring out what "just enough" is, is tough. Sometimes I make enough, sometimes I don't. The most troublesome challenge is walking the fine line between voluntary simplicity and involuntary poverty.

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The other challenge is not giving in to the opportunities to make the big bucks. A couple of times, I've headed off to teach myself new skills (coaching, consulting, etc) and did so well I was tempted to just keep at it to bring in the big bucks, sock them away in an FI fund (a la Your Money or Your Life?), but I found that when I did that kind of work, my expenses went way up (marketing, promotion, new clothes, nice car, air fare for travel, hotels in the city, all the things you need to do to appear a successful consultant). In the end, I didn't take home much more money than I did when I lived close to the bone, so I bagged most of that stuff. Now I only do work for groups I like and only occasionally.

The thing I like best about living simply is the time and freedom it gives me to create (write, relationships,) and to be in the natural world appreciating where I live.

Tammie: In your article, "Living Well, Living Deeply," you assert that lasting change requires "more than mere surface changes in behavior..." but re-arranging "the deeper elements underlying our actions." If you were to explain what you mean by this to an adolescent, what would you say?

Bruce: There are some things that adolescents can't or are not ready to hear, especially those under 15 years. There is a brain growth spurt at +/-14. Before that growth happens, they are still very concretely focused. Some of the structural stuff I work with just goes over their heads. When I do talk to older adolescents about this stuff, I talk about the difference between long-term goals/desires that really matter and short-term demands and how to organize your response to short-term demands so it both gives you what you want now and supports your long term desires. They usually get that.

Tammie: What are the "basic processes underlying the ability to create?"

Bruce: The basic processes underlying the ability to create are:

1. Knowing what you want, being able to envision a completed result in enough detail that you would recognize it if you created it.

2. Knowing what you have, being able to ground yourself in an objective and accurate description (not judgment!) of current reality, i.e. where you are starting from, what you have working for you, against you, what skills, resources, talents, experience etc you have or do not have.

3. The capacity to hold Vision and Current Reality together in your mind at the same time and to live/work comfortably in the gap between Vision and Reality as you craft your creation/desired result step by step.

4. A hierarchical set of choices wherein day to day choices support strategic goals and objectives and strategic goals support long-term purposes and your life mission.

5. The capacity to learn from doing, to try, note results, learn, make adjustments and try again.

6. Momentum: through consistent action, even wrong actions, you keep the momentum flowing. Over time it becomes a force which helps you move toward completion. The key is to always know your next steps, where you're going after you've done the step you're on now.

7. Completion: finishing fully, adding touches and details, making the creation fit the vision in your mind of what it looks like done.

8. Receiving: becoming a non-attached observer/critic of your creation. Being willing to live with its greatness and its faults without seeing either as reflective on you.

9. Using the energy of completion to begin your next creation.

Tammie: Has there been a particular transformative experience in your own life?

Bruce: I'm not a fan of cataclysmic theories of change. I don't think in terms of breakthroughs to higher levels (except in terms of chaos theory's bifurcations, but those are beyond my full understanding), I don't think in terms of quick fixes. I think more in terms of how nature usually works, slowly, consistently, patiently building things up over time. That's also how most art, literature, music, etc is created, step by step, poco a poco. My life has worked that way. No big quakes or shifts, just slow, incrementally building, growing learning over time. Eventually I've found myself miles from where I began.

Tammie: Do you believe that it's possible that we may be experiencing a global 'quake?'

Bruce: It is possible that the earth system is becoming so chaotic that we're about to experience a chaotic bifurcation, but I don't think anyone really knows if this is true or not. I think it is more likely that we're gonna continue muddling on, new things will emerge out of the mix, some will take, some will fall away and we'll gradually move closer to what we all really want. Wendell Berry said about learning to live where you are - Love the neighbors you have, not the ones you wish you had.) I think the key thing for all of us to do is not put our faith in big, sudden shifts but to settle in to our selves, our communities and our world for the long haul. We need to learn to be happy with and to want what we have! We need to love the world we have and work hard to bring into being the things we want in that world. And ourselves!

Tammie: What concerns you the most about our 'collective future,' what gives you the most hope?

Bruce: Not much concerns me about our future, because all the world is way out of my control. I am hopeful that the human spirit, which is part of nature's grand, intelligent complexity, will soar high enough to help our species realize that we are, indeed, just plain citizens of the biotic community and to begin to re-invent our lives, business and communities to fit into that biotic community in harmony with the systems that sustain all life. We may have to do some more real dumb stuff, screw up big time here and there, before everyone "gets it". But, I think we will, eventually. By we I mean humanity, our kids and their kids and their kids kids. In the meantime, I'm trying very much to enjoy what I have, the only life I'm likely to get.

next: On the Death of a Child

Family members, friends are often shocked when learning of the self-injurious activities of a loved one. Dr. Tracy Alderman, the author of "The Scarred Soul," discusses how to help the person who self-injures.

After having an awful day at work and an even worse time fighting the traffic to come home, Joan wanted nothing more than to sit down on her couch, turn on the television, order out for pizza and relax for the rest of the evening. But when Joan walked into the kitchen, what she saw indicated that this would not be the evening of her dreams. Standing in front of the sink was her fourteen-year-old daughter, Maggie. Maggie's arms were covered with blood, long slashes on her forearms dripping fresh blood into the running water of the kitchen sink. A single-edged razor blade sat on the counter along with several once-white towels, now stained crimson by Maggie's own blood. Joan dropped her briefcase and stood before her daughter in silent shock, unable to believe what she saw.

It is likely that many of you have had a similar experience and reaction to learning of the self-injurious activities of a loved one. This article is intended to provide some support, advice, and education to those of you who have friends and family who engage in activities of self-inflicted violence.

Self-Inflicted Violence: The Basics

Self-Inflicted Violence (SIV) is best described as the intentional harm of one's own body without conscious suicidal intent. Most types of SIV involve cutting of one's own flesh (usually the arms, hands, or legs), burning one's self, interfering with the healing of wounds, excessive nail biting, pulling out one's own hair, hitting or bruising one's self, and intentionally breaking one's own bones. SIV is more common than you might think with roughly 1% of the general population engaging in these behaviors (and this is likely to be greatly underestimated). The explanations for why people intentionally injure themselves are numerous and diverse. However, most of these explanations indicate that SIV is used as a method of coping and tends to make life more tolerable (at least temporarily).

How Can I Help Those Who Are Hurting Themselves?

Unfortunately, there is no magic cure for self-inflicted violence. However, there are some things which you can do (and some things you shouldn't do) which can help those individuals who are hurting themselves. Keep in mind though, that unless someone wants your help, there is nothing in the world that you can do to assist that individual.

Talk About Self-Inflicted Violence

SIV exists whether you talk about it or not. As you know, ignoring anything does not make it disappear. The same is true with self-inflicted violence: it will not go away because you are pretending it doesn't exist.

Talking about self-inflicted violence is essential. Only through open discussions of SIV will you be able to help those who are hurting themselves. By addressing the issues of self-injury you are removing the secrecy which surrounds these actions. You are reducing the shame attached to self-inflicted violence. You are encouraging a connection between you and your self-injuring friends. You are helping to create change just by the mere fact that you are willing to discuss SIV with the person who performs those behaviors.

You may not know what to say to the individual who is performing acts of SIV. Fortunately, you don't have to know what to say. Even by acknowledging that you want to talk, but you're not sure how to proceed, you are opening the channels of communication.

Be Supportive

Talking is one way to provide support, however, there are numerous other ways to show your support to another. One of the most helpful ways by which to determine how you could offer support is to directly ask how you might be helpful. In doing so, you might find that your idea of what is helpful is vastly different from how others view what is helpful. Knowing what kind of assistance to offer and when to offer it is necessary in order to be helpful.

Although it may be difficult for you, it is really important that in being supportive you keep your negative reactions to yourself. Because judgments and negative responses contrast with support, you will need to put these feelings aside for the time being. You can only be supportive when you act in supportive ways. This is not to say that you should not or will not have judgments or negative reactions to SIV. However, conceal these beliefs and feelings while you are performing helpful behaviors. Later, when you are not assisting your friend, go ahead and release these thoughts and emotions.

Be Available

Most individuals who injure themselves, will not do so in the presence of others. Therefore, the more you are with those individuals who hurt themselves, the less opportunity they will have to inflict self-harm. By offering your company and your support, you are actively decreasing the likelihood of SIV.

Many people who hurt themselves have difficulty recognizing or stating their own needs. Therefore, it is helpful for you to offer the ways in which you are willing to help. This will allow your friends to know when and in what ways they are able to rely on you.

You will need to set and maintain clear and consistent limits with your self-injuring friends. Thus, if you are not willing to take crisis calls after nine in the evening, then indicate this to your friends. If you can only offer support over the telephone, rather than in person, be clear about that. When individuals need support around issues of SIV, they need to know who is available to help them and in what manner they can offer help. While what you do for your friends is important, establishing and maintaining appropriate boundaries is equally necessary for the relationship (and your own sanity).

Don't Discourage Self-Injury

Although this may seem difficult and irrational, it is important for you to not discourage your friends or family from engaging in acts of self-inflicted violence. Rules, shoulds, shouldn'ts, dos and don'ts all limit us and place restrictions on our freedom. When we maintain the right to choose, our choices are much more powerful and effective.

Telling an individual to not injure herself is both aversive and condescending. Because SIV is used as a method of coping and is often used as an attempt to relieve emotional distress when other methods have failed, it is essential for the person to have this option. Most individuals would choose to not hurt themselves if they could. Although SIV produces feelings of shame, secrecy, guilt and isolation, it continues to be utilized as a method of coping. That individuals will engage in self-injurious behaviors despite the many negative effects is a clear indication of the necessity of this action to their survival.

Although it may be incredibly difficult to witness a loved one's fresh wounds, it is really important that you offer support, and not limits, to that individual.

Recognize the Severity of the Person's Distress

Most people don't self-injure because they're curious and wonder what it would be like to hurt themselves. Instead, most SIV is the result of high levels of emotional distress with few available means to cope. Although it may be difficult for you to recognize and tolerate, it is important that you realize the extreme level of emotional pain individuals experience surrounding SIV activities.

Open wounds are a fairly direct expression of emotional pain. One of the reasons why individuals injure themselves is so that they transform internal pain into something more tangible, external and treatable. The wound becomes a symbol of both intense suffering and of survival. It is important to acknowledge the messages sent by these scars and injuries.

Your ability to understand the severity of your friend's distress and empathize appropriately will enhance your communication and connection. Don't be afraid to raise the subject of emotional pain. Allow your friends to speak about their inner turmoil rather than express this turmoil through self-damaging methods.

Get Help For Your Own Reactions

Most of us have had the experience at some point in our lives of feeling distressed by our reactions to someone else's behavior. Al-Anon and similar self-help groups were created to help the friends and families of individuals dealing with problems of addiction and similar behaviors. At this point in time, no such organizations exist for those coping with a loved one's SIV behaviors. However, the basic premise upon which these groups were designed clearly applies to the issue of self-inflicted violence. Sometimes the behavior of others affects us in such a profound manner that we need help in dealing with our reactions. Entering psychotherapy to deal with your responses to SIV is one such way to handle the reactions which you may find to be overwhelming or disturbing.

You may find it strange to seek help for someone else's problem. However, the behaviors of others can have profound effects on us. This effect is further strengthened by the mysteriousness, secrecy, and misconceptions about self-inflicted violence. Thus, entering psychotherapy (with a knowledgeable clinician) can educate you about SIV as well as assist you in understanding and altering your own reactions. When you learn that a friend or family member is injuring herself, you are likely to have an intense emotional reaction and psychotherapy will help you deal with these reactions.

Sometimes asking for help is really difficult. The individuals who have come to you telling you of their SIV and asking for your help are highly aware of this. Follow in their path. If you need (or want) help, get it. Seek a trained professional. Ask some friends for support. Speak with a religious counsel if that's helpful. Whatever you need to do in order to take care of yourself, do it. You have to take care of yourself before you can assist another. When trying to help friends and family members who are injuring themselves, this point is critical. We cannot be of much use to anyone else if we, ourselves are in a state of need.

Tracy Alderman, Ph.D., is a licensed clinical psychologist and author of a well-known book on self-injury, "The Scarred Soul".

Tips for parents and teens on getting help for dealing with and stopping self-injury.

Parents are encouraged to talk with their children about respecting and valuing their bodies. Parents should also serve as role models for their teenagers by not engaging in acts of self-harm. Some helpful ways for adolescents to avoid hurting themselves include learning to:

• accept reality and find ways to make the present moment more tolerable.
• identify feelings and talk them out rather than acting on them.
• distract themselves from feelings of self-harm (for example, counting to ten, waiting 15 minutes, saying "NO!" or "STOP!," practicing breathing exercises, journaling, drawing, thinking about positive images, using ice and rubber bands)
• stop, think, and evaluate the pros and cons of self-injury.
• soothe themselves in a positive, non-injurious, way.
• practice positive stress management.
• develop better social skills.

Evaluation by a mental health professional may assist in identifying and treating the underlying causes of self-injury. Feelings of wanting to die or kill themselves are reasons for adolescents to seek professional care right away. A child and adolescent psychiatrist can also diagnose and treat the serious psychiatric disorders that may accompany self-injurious behavior.

See also "Self-Help for Self-Injury"

Source:

• The American Academy of Child and Adolescent Psychiatry (AACAP)

How can a person who self-injures stop this self-harming behavior? Here are some good self-harm coping skills.

Most people who self-harm want to stop hurting themselves and they can do this by trying to develop new ways of coping and communicating. However, some people feel a need not only to change their behavior but also to understand why they have resorted to harming themselves.

There are a number of techniques that can reduce the risk of serious injury or minimize the harm caused by self-inflicted injury. This list is not exhaustive - different people find different things useful in various situations. So if one doesn't work, try another.

• stop and try to work out what would have to change to make you no longer feel like hurting yourself
• count down from ten (nine, eight, seven)
• point out five things, one for each sense, in your surroundings to bring your attention on to the present
• breathe slowly - in through the nose and out through the mouth.

If you still feel like cutting, try:

• marking yourself with a red water-soluble felt-tip pen instead of cutting
• a punch bag to vent the anger and frustration
• plunging your hands into a bowl of ice cubes (not for too long, though)
• rubbing ice where you'd otherwise cut yourself

There are several other things you can do to help yourself better cope with self-injury:

• Acknowledge that this is a problem, that you are hurting on the inside, and that you need professional assistance to stop injuring yourself.
• Realize that this is not about being bad or stupid - this is about recognizing that a behavior that somehow was helping you handle your feelings has become as big a problem as the one it was trying to solve in the first place.
• Find one person you trust - maybe a friend, teacher, minister, counselor, or relative - and say that you need to talk about something serious that is bothering you ("How Do You Tell Someone You Self-Injure?").
• Get help in identifying what "triggers" your self-harming behaviors and ask for help in developing ways to either avoid or address those triggers.
• Recognize that self-injury is an attempt to self-sooth, and that you need to develop other, better ways to calm and sooth yourself.

Sources:

Helpguide.org

There is no magic pill for stopping self-harm. Therapeutic approaches help people who self-injure to learn new coping mechanisms to deal with feelings instead of self-injury.

Self-harm is almost always a symptom of another problem comorbid to self-injury. While the problem can be addressed directly through behavioral and stress-management techniques, it may also be necessary to look at and treat other problems. This could involve anything from medication to psychodynamic therapy.

Current methods of treatment involve using medications such as antidepressants, mood stabilizers and anti-anxiety drugs to alleviate the underlying symptoms that patients are attempting to cope with via self-injury. Once the patient becomes stabilized on medication, deeper therapeutic work must be done to deal with any underlying problems that are contributing to these symptoms. Long-term recovery from self-injury involves learning new techniques for coping with turbulent emotions. Perhaps most importantly, patients need to be treated with compassion rather than force.

Hospitalization and taking away implements used for self-injury may make friends and family feel more secure, but the patient is left feeling fearful and completely defenseless. Long-term healing involves helping the patient to control symptoms in a more positive way, such as journaling and anger management skills. If a negative coping skill is removed, it is crucial to replace it with a more positive one. The patient's desire to cooperate and get well is a major factor in recovery.

Finding a Specialist to Treat Self-Injury

Of all disturbing patient behaviors, self-mutilation is often described as the most difficult for clinicians to understand and treat. Typically, these therapists and mental health practitioners are left feeling a combination of helplessness, horror, guilt, fury, and sadness.

Most local mental health teams are prepared to see and assess people who self-harm but, where the underlying problems are too complex, may decide to refer the patient to more specialized services.

There are very few self-injury treatment centers / programs in the U.S. where staff members have the necessary training and experience to allow them to confront and manage such seemingly bizarre behavior. One is the S.A.F.E. Alternatives program, a specialist treatment center for those who suffer from self-injury.

If you are searching for professional help, ask your doctor for a referral, call your county medical society and county psychological association along with area psychiatric hospitals.

When telling someone you self-harm, there are many things to take into consideration. Consider revealing your self-injury to someone you trust.

Telling someone that you are a self-injurer is scary. You don't know how they will react. In a way, it can be viewed as similar to coming out as gay or lesbian. Although it is very common, it may not be considered "acceptable" to others. Be careful whom you choose to tell. Choose someone you really trust. You can disclose in a conversation or in a letter that you present to them or by e-mail. If you choose the last two, be ready to follow it up with a chat session or phone call.

Keep these points in mind:

• Be willing to give the person some time to digest what you have told them. You may have caught them by surprise and first reactions are not always the best indicators of their feelings. Give them some space, but be ready for their questions.
• Be as open as you can and give them as much information as you can. Give them internet addresses like this one or ways to get additional information or books to read. People are afraid of things that they don't understand.
• Try to anticipate what questions they might ask. If they ask you something that you are not ready to talk about yet, tell them that.
• Realize that it can be as difficult for them to hear what you have to say, as it is for you to say it. Anyone that you are that close to will not want you to hurt and will want to help. They may wonder where they went wrong and feel guilty that they did not notice. Be sure to tell them that this is a choice you made and you were not ready for their help earlier but need it now.
• You do not have to accept their value judgments about your self-injury.
• Let the person know you are telling them because you trust them, not because you are trying to punish, manipulate or guilt-trip them.
• Never tell someone in anger. ("You made me cut/burn/hit.") Do not blame the person for their behaviors which may have triggered you or for not seeing your pain. They'll get defensive and angry. You want their understanding, not their guilt and besides, self-injury is always your choice.
• If you have a friend or a counselor that you trust you may want them to be present to give you support, but do not expect them to tell the other person for you.
• It's usually best to avoid graphic descriptions of your injuries. You are not trying to freak them out. They probably don't need a technicolor description of your worst incident. If they have any questions later then you can give them the details in another conversation once they have had a chance to absorb what you told them.

For many people, the thought of self-injury is shocking; an incomprehensible thought. Here are the reasons why people self-injure, engage in self-injurious behaviors, and commit acts of self-harm.

For many, self-harming behavior starts in childhood, disguising scratches and bumps as accidents and progressing to more systematic cutting and burning in adolescence.

There are different theories as to why people self-mutilate. One is that because victims of childhood sexual abuse were forbidden to reveal the truth about their abuse, they use self-mutilation or self-cutting to express the horror of their abuse to the world.

Another theory is that sexual abuse in early childhood leads to extremely low self-esteem. If very low self-esteem develops, self-harm as an expression of self-hatred is understandable.

One research finding is that self-harmers tend to grow up in an 'invalidating environment' - one where the communication of private experiences is met with unreliable, inappropriate or extreme responses. As a result, expressing private experiences is not validated, instead, it's trivialized or punished.

The problem with these theories is that (in the case of the sexual abuse theory, for example) not everyone who's been sexually abused starts to self-harm, and not everyone who self-harms has been sexually abused.

Pain and Pleasure of Self-Injury

Another theory for self-cutting is that it triggers release of the body's natural opiate-like chemicals to reduce the pain. Perhaps self-cutters have become addicted to their body's heroin-like reaction to cutting, which is why they do it again and again. They may also experience withdrawal if they haven't done it for a while.

Drugs used to treat heroin addicts may be helpful with self-cutters, but mostly for those who describe a 'high' after they've cut themselves.

Another theory, which in-patient units often use, is based on the psychological principle that all behavior has consequences that are somehow rewarding. Cutting usually leads to a sequence of behavior - increased attention, for example - that may become a rewarding reason to repeat the behavior.

Staff in hospital specialist units are specially trained to ensure that no consequences follow from an episode of cutting that could be rewarding. Instead, when the patient stops cutting themselves they're rewarded with increased attention from staff.

Sources:

• Favazza, A. R. (1989). Why patients mutilate themselves. Hospital and Community Psychiatry.
• Solomon, Y. & Farrand, J. (1996). "Why don't you do it properly?" Young women who self-injure. Journal of Adolescence, 19(2), 111-119.
• Miller, D. (1994). Women Who Hurt Themselves: A Book of Hope and Understanding. New York: BasicBooks.

Self-injury is defined as any intentional injury to one's own body. It can include cutting, burning, and other forms of self-harm, self-mutilation. Here are the signs of self-injury.

People who self-harm become very adept at hiding scars or explaining them away. Look for signs such as a preference for wearing concealing clothing at all times (e.g. long sleeves in hot weather), an avoidance of situations where more revealing clothing might be expected (e.g. unexplained refusal to go to a party), or unusually frequent complaints of accidental injury (e.g. a cat owner who frequently has scratches on their arms).

Types of Self-Harm

The most common forms are cutting the arms, hands, and legs, and less commonly the face, abdomen, breasts and even genitals. Some people burn or scald themselves, others inflict blows on their bodies, or bang themselves against something.

Other forms of self-harm include scratching, picking, biting, scraping and occasionally inserting sharp objects under the skin or into body orifices, and swallowing sharp objects or harmful substances ("Why Do Self-Injurers Engage in Self-Harm?").

Common forms of self-injury that rarely reach medical attention include people pulling out their own hair and eyelashes, and scrubbing themselves so hard they break the skin (sometimes using cleaners such as bleach).

Additional forms of self-harm may include:

• carving
• branding
• marking
• biting
• headbanging
• bruising
• hitting
• tattooing
• excessive body piercing

There are various reasons why self-injurers hurt themselves. However, self-injurers also share common psychological characteristics.

Although self-injury is recognized as a common problem among the teenage population, it is not limited to adolescents. People of all sexes, nationalities, socioeconomic groups and ages can be self-injurers.

Self-injurers suffer in silent shame and isolation. It is estimated that self-injurers comprise at least 1% of the population, with a higher proportion being female, and nearly half admitting to being victims of physical and/or sexual abuse in childhood. A significant number of self-mutilators also suffer from eating disorders, alcohol abuse and/or drug abuse problems, personality disorders, and/or mood disorders. While each self-mutilator has a different story to tell, all share certain characteristics:

• The self-harm behavior is recurrent.
• The self-injurer experiences a mounting sense of fear, dread, anxiety, anger, or tension before the event.
• A sense of relief accompanies the event.
• A sense of deep shame follows.
• The self-injurer attempts to cover-up any evidence (e.g. scars) of his/her act.

More on the psychological characteristics common in self-injurers here

The Adolescent Self-injurer

Some adolescents may self-mutilate to take risks, rebel, reject their parents' values, state their individuality or merely be accepted. Others, however, may injure themselves out of desperation or anger to seek attention, to show their hopelessness and worthlessness, or because they have suicidal thoughts. These children may suffer from serious psychiatric problems such as depression, psychosis, Posttraumatic Stress Disorder (PTSD) and Bipolar Disorder. Additionally, some adolescents who engage in self-injury may develop Borderline Personality Disorder as adults. Some young children may resort to self-injurious acts from time to time but often grow out of it. Children with mental retardation and/or autism as well as children who have been abused or abandoned may also show these behaviors.

Sources:

• Levenkron, S. (1998) Cutting: Understanding and Overcoming Self-Mutilation. New York: W. W. Norton
• The American Academy of Child and Adolescent Psychiatry, Self-Injury In Adolescents, No. 73, Dec. 1999.

next: Who self-injures? Psychological Characteristics Common in Self-Injurers