About Self-Injury

About self-injury ¹ . . .

Self-injury basics:

Most researchers agree that self-injury (SI) is self-inflicted physical harm severe enough to cause tissue damage or marks that can last for several hours, done without suicidal intent, or to attain sexual pleasure. Body markings or modifications that are done as part of a spiritual ritual or for ornamentation purposes generally aren’t considered SI

SI generally is done as a way of coping with overwhelming mental or physical arousal. This can be done to express emotion, to deal with feelings of unreality or numbness, to make flashbacks stop, to self-punish and stop self-hating thoughts, or to deal with tension or distress than it is about anything else.

Although cutting is the most common form of SI burning and head-banging are also very common. Other forms include biting, skin-picking, hair-pulling, hitting the body with objects, or hitting objects with the body.

SI is a crude, ultimately destructive coping mechanism, but it works. That’s why it sometimes seems to have addictive qualities. To help a client, you must offer more effective coping strategies as replacement. Learning these ways can take time; punishing a client or patient for coping in the only way he or she knows can make therapy unworkable.

Most people who self-injure hate the term “self-mutilation.” That phrase refers to intent, and maiming the body is usually not the intention of SI anyway. Better terms are self-inflicted violence, self harm, and self-injury.

Why people self-injure:

Self-injury is probably the result of many different factors. Among them:

Lack of role models and invalidation - most people who are self-injurers have been chronically invalidated in some way as children (many self-injurers report abuse or rejection, but almost all report chronic undermining of their self-worth). They have never learned appropriate ways of expressing emotion and may have learned that emotions are bad and to be avoided.

Biological predisposition - evidence is accumulating that indicates self-injurers have specific problems with the brain’s serotonic system that cause an increase in impulsivity and aggression. Impulsive aggression combined with a belief that expressing it outwardly is unthinkinkably bad, might lead to an aggression being turned outward.

Reduction of tension - Studies have suggested that when people who self-imjure get emotionlly overwhelmed, an act of self-harm almost immediately brings their levels of tension and arousal back to back to bearable levels. In other words, they feel a strong uncomfortable emotion, don’t know how to handle it, and know that hurting themselves will reduce the emotional discomfort quickly. They may still feel bad, but they don’t have that panicky, jittery, trapped feeling.

Who is likely to self injure?

Self- injurers come from all walks of life and all economic brackets. People who harm themselves may be male or female; gay, straight or bi; Ph.D.’s or high-school dropouts; rich or poor; and live in any country in the world. Some people who SI manage to function in demanding jobs; they are teachers, therapists, medical professionals, lawyers, professors, engineers. Some are on disability. Some are highly achieving high-school students.

Their ages typically range from early teens to early 60's, although they may be older or younger. In fact, the incidence of self-injury is about he same at that of eating disorders, but because it is so highly stigmatized, most people hide their scars, burns, and bruises carefully. They also have excuses to offer when someone asks about the scars (there are a lot of really vicious cats around!).

People who deliberately harm themselves are no more psychotic than are people who drown their sorrows in a bottle of vodka. It’s a coping mechanism, just not one that’s as understandable to most people and as accepted by society as alcoholism, drug abuse, over-eating, anorexia, bulimia, workaholism, smoking cigarettes, and other forms of problem avoidance are.

Self injury is only rarely a suicide attempt. People who inflict physical harm on themselves are often doing it in an attempt to maintain psychological integrity - it is a way to keep themselves from suicide. They release unbearable feelings and pressures through self-harm, easing their urge towards suicide. Some people who self-injure do later attempt suicide, but they almost always use a method different from their preferred method of self-harm. Self-injury is a maladapative coping mechanism, a way to stay alive. Unfortunately, some people don’t understand this and think that involuntary commitment to hospital is the only way to deal with a person who self-harms. Hospitalization, especially forced, can do more harm than good.

Suggestions for helpers:

Medications (mood stabilizers, anxiolytics, anti-depressants and some of the newer neuroleptics) have been tried with some success. There is no magic pill for stopping self-harm. Many therapeutic approaches are being developed to help self-harmers learn new coping mechanisms and teach them how to use those techniques instead of self-injury. This reflects a growing belief among mental-health workers that once a client’s patterns of self-inflicted violence stabilize, work can be done on the problems and issues underlying self-injury.

This does not mean that patients should be coerced into stopping self-injury. Any attempts to reduce or control the amount of self-harm a person does should be based on the clients willingness to undertake the difficult work of controlling and/or stopping self-injury. Treatment should not be influenced by the practitioner’s personal feelings about the practice of self-harm.

Self-injury brings out many uncomfortable feelings in helpers: revulsion, anger, fear, and distaste, to name a few. Medical professionals who are unable to cope with their own feelings about self-harm have an obligation to themselves and to their clients to find a practitioner willing to do this work. In addition, they are responsible for ensuring that the client understands that the referral is due to their own inability to deal with self-injury and not to inadequacies in the client

People who self-injure generally do so because of an internal dynamic and not in order to annoy, anger or irritate others. Their self-injury is a behavioural response to an emotional state and is usually not done to frustrate caretakers. In emergency rooms, people with self-inflicted wounds are often told indirectly and directly that they are not deserving of care as someone who has an accidental injury. They may be treated badly the same doctors who would not hesitate to do everything possible to preserve the weight, sedentary heart-attack patient.

Physicians and nurses in emergency rooms or urgent-care clinics should be sensitive to the needs of patients who come in to have self-inflicted wounds treated. If the patient is calm, denies suicidal intent, and has a history of SI,the doctor should treat the wounds as they would treat accidental injuries. Refusing to provide anaesthesia for stitches, making disparaging remarks, and treating the patient as an inconvenient nuisance simply worsen the feelings of invalidation and unworthiness the self-injurer has.

It is useful to offer mental health follow-up services; however, psychological evaluations with an eye toward hospitalization should be avoided in the ER unless the person is clearly a danger to self or to others. In places where people know that seeking treatment for self-inflicted injuries are liable to lead to lengthy evaluations and mistreatment, patients are much less likely to seek medical attention and thus are at higher risk for wound infections and other complications.