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Self-Injury: You are NOT the only one.

Monday, March 1, 2004 is SI Awareness Day.


It is estimated that somewhere from 3 million Americans self injure in some way. 2 million Americans cut or burn themselves. 90% of that 3 million begin as teenagers. Although most of them seem to be women, up to 40% are men. Self injury is prevalent in ALL races and ALL economic backgrounds. Most self injurers are NOT trying to commit suicide, instead using it as a coping mechanism. Self Injurers are NOT crazy. Self injury consists of more than just burning. Eating disorders, drug and alcohol abuse, breaking of bones on purpose, and scratching are some other examples.

The rights of the Self Injurer:

Right to caring, human medical treatment
Right to participate fully in decisions about medical psychiatric treatment (as long as no one is in immediate danger)
Right to body privacy
Right to have the feelings behind the self injury validated
Right to disclose to whom they choose what they choose
Right to choose what coping mechanisms they will use
Right to have care providers who are not afraid of self injury
Right to have the role self injury as played as a coping mechanism validated
Right to not be automatically considered a dangerous person simply because of self injury
Right to have self injury regarded as an attempt to communicate, not manipulate

** Self-injury basics **

* Most researchers agree that self injury (SI) is self-inflicted physical harm severe enough to cause tissue damage or marks that last for several hours, done without suicidal intent or intent to attain sexual pleasure. Body markings (piercing, tattooing, etc) 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 psychophysiological arousal. This can be to express emotion, to deal with feelings of unreality or numbness, to make flashbacks stop, to punish the self and stop self-hating thoughts, or to deal with a feeling of impending explosion. SI is more about relieving tension or distress than is it 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, etc.

* 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 s/he knows how can make therapy unworkable.

* Most people who self-injure hate the term "self-mutilation." That phrase speaks to intent and maiming the body is usually not the intent of SI anyway. Better phrases 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 self-injure were chronically invalidated in some way as children (many self-injurers report abuse, but almost all report chronic invalidation).They 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 within the brain's serotonergic system that cause an increase in impulsivity and aggression. Impulsive aggression, combined with a belief that expressing it outwardly is a very bad thing, might lead to the aggression being turned inward.

* Studies have suggested that when people who self-injure get emotionally overwhelmed, an act of self-harm brings their levels of psycho-physiological tension and arousal back to a bearable baseline level almost immediately. 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 extremely quickly. They may still feel bad (or not), but they don't have that panicky jittery trapped feeling; it's a calm bad feeling.

** Who is likely to self-injure **

* Self-injurers come from all walks of life and all economic brackets. People who harm themselves can be male or female; gay, straight, or bi; Ph.D.s or high-school dropouts; rich or poor; from any country in the world. Some people who SI manage to function effectively 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 range from early teens to early 60s, maybe older and younger. In fact, the incidence of self-injury is about the same as that of eating disorders, but because it's so highly stigmatized, most people hide their scars, burns, and bruises carefully. They also have excuses to pull out 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 people who drown their sorrows in a bottle of vodka are. It's a coping mechanism, just not one that's as understandable to most people and as accepted by society as alcoholism, drug abuse, overeating, anorexia, bulimia, workaholism, smoking cigarettes, and other forms of problem avoidance are.

* Self-injury is VERY RARELY a failed suicide attempt. People who inflict physical harm on themselves are often doing it in an attempt to maintain psychological integrity -- it's a way to keep from killing themselves. They release unbearable feelings and pressures through self-harm, and that eases their urge toward 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 maladaptive coping mechanism, a way to stay alive. Unfortunately, some people don't understand this and think that involuntary commitment is the only way to deal with a person who self-harms. Hospitalization, especially forced, can do more harm than good.

** What helps people who self-injure **

Medications (mood stabilizers, anxiolytics, antidepressants, and some of the newer neuroleptics) have been tried with some success. There is no magic pill for stopping self-harm (naltrexone, though effective in people with developmental disabilities, doesn't seem to work nearly as well in other patients). Many therapeutic approaches have been and are being developed to help self-harmers learn new coping mechanisms and teach them how to start using those techniques instead of self-injury. They reflect a growing belief among mental-health workers that once a client's patterns of self-inflicted violence stabilize, real work can be done on the problems and issues underlying the 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 in the client's willingness to undertake the difficult work of controlling and/or stopping self-injury. Treatment should not be based on a practitioner's personal feelings about the practice of self-harm.

Self-injury brings out many uncomfortable feelings in people: revulsion, anger, fear, and distaste, to name a few. If a medical professional is unable to cope with her own feelings about self-harm, then she has an obligation to herself and to her client to find a practitioner willing to do this work. In addition, she has the responsibility to be certain the client understands that the referral is due to her own inability to deal with self-injury and not to any inadequacies in the client.

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

Doctors in emergency rooms and 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 anesthesia for stitches, making disparaging remarks, and treating the patient as an inconvenient nuisance simply further 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 him/herself or to others. In places where people know that seeking treatment for self-inflicted injuries are liable to lead to mistreatment and lengthy psychological evaluations, they are much less likely to seek medical attention for their wounds and thus are at a higher risk for wound infections and other complications.

Guidelines to dealing with a friend or family member who self injures:

1. Don't take it personally.

Self-injurious behavior is more about the person who does it than about the people around him/her. The person you're concerned about is not cutting, burning, hitting, or whatever just to make you feel bad or guilty. Even if it feels like a manipulation, it probably isn't intended as one. People generally do not SI to be dramatic, to annoy others, or to make a point.

2. Educate yourself.

Get as much information as you can about self-injury in general.

3. Understand your feelings.

Be honest with yourself about how this self-injury makes you feel. Don't pretend to yourself that it's okay if it's not -- many people find self-injury repulsive, frightening, or provoking (Favazza, 1996; Alderman, 1997). If you need help dealing with the feelings aroused in you by self-injury, find a good therapist. Be careful, though, that you not try to get "surrogate therapy" for your family member/friend -- what goes on in your therapy sessions should remain between you and your therapist. Don't ask your therapist to try to diagnose or treat the person you're concerned about, and if the self-injurer seeks treatment, be sure that s/he is seeing a different therapist than you are. Don't discuss the content of your therapy sessions in any but the most general terms, and never say anything like "My therapist says you should..." Therapy is a tool for self-understanding, not for getting others to change.

4. Be supportive without reinforcing the behavior.

Some good ways of showing support include:

*Don't avoid the subject of self-injury. Let it be known that you're willing to talk, and then follow the other person's lead. Tell the person that if you don't bring the subject up, it's because you're respecting their space, not because of aversion.
*Make the initial approach. "I know that sometimes you hurt yourself and I'd like to understand it. People do it for so many reasons; if you could help me understand yours, I'd be grateful." Don't push it after that; if the person says they'd rather not talk about it, accept this gracefully and drop the subject, perhaps reminding them that you're willing to listen if they ever do want to talk about it.
*Be available
*Set reasonable limits. "I cannot handle talking to you while you are actually cutting yourself because I care about you greatly and it hurts too much to see you doing that" is a reasonable statement, for example. "I will stop loving you if you cut yourself" isn't reasonable if your goal is to keep the relationship intact.
*Make it clear from your behavior that the person doesn't need to self-injure in order to get displays of love and caring from you. Be free with loving, caring gestures, even if they aren't returned always (or even often). Don't withdraw your love from the person. The way to avoid reinforcing SIV is to be consistently caring, so that taking care of the person after they injure is nothing special or extraordinary.
*Don't ask "Is there anything I can do?" Find things that you can do and ask "Can I ?" People who feel really bad often can't think of anything that might make them feel better; asking if you can take them to a movie or wash those (month-old) dishes (if done nonjudgmentally) can be really helpful. Spontaneous acts of kindness ("I saw this flower at the store and knew you'd love to have it") work wonders.

5. Ultimatums do NOT work. EVER!

6. Acknowledge the pain of your loved one.

Accepting and acknowledging that someone is in pain doesn't make the pain go away, but it can make it more bearable. Let them know you understand that SIV isn't an attempt to be willful or to make life hard for you or to be unpleasant; acknowledge that it's caused by genuine pain they can find no other way to handle. Be hopeful about the possibility of learning other ways to cope with pain. If they're open to it, discuss possibilities for treatment with them.

7. Don't force things.

If you make overtures and they're rejected, back off for a few days or weeks. Don't push it. Some people need time to decide to trust someone else, particularly if they've received a lot of negative feedback about their SI before. Be patient.

To anyone who has read this far, I thank you for your time.

“Whatever you did for one of the least of these brothers of mine, you did for me”
---Matthew 25:40

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