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Articles about Self-Injury

  Self-inflicted violence: Helping those who hurt themselves

© Tracy Alderman, Ph.d., Original location

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 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, than 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.

About the author

Tracy Alderman, Ph.D. is a licensed clinical psychologist residing in San Diego, California. She is the Director of Research at the University for Humanistic Studies and an adjunct instructor at Chapman University. She is also a staff psychologist for the California Department of Corrections. Dr. Alderman is currently writing a book on the topic of self-inflicted violence.

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  Affirmations for people who self-harm

from Self-Harm Overcome by Understanding and Tolerance (SHOUT), Original location

Affirmations are positive, caring messages for us to give ourselves. Most people who self-harm tell themselves a lot of negative and painful things. Affirmations can be good things to say to yourself to help you feel a bit better. You can also write them up on the wall to look at during hard times. What you need to say to yourself is different at different times. Here are some we have written and hope are useful; you could write some for yourself too.

My feelings are real and important and need to be listened to.

There are good reasons for the pain I feel. But it doesn't have to last forever. I deserve to have the support I need to get over the things that have hurt me.

When I feel bad or guilty or dirty, that's how I have been made to feel by things that have happened in my life. It's not the truth about me.

I am a real, worthwhile, good person who deserved to be respected and cared about.

In my heart of hearts, I know what I feel and what I need. I can trust and respect myself. I can stand up for what is right for me.

I have suffered more than enough in my life. I can have some kindness now. I don't deserve to be hurt anymore.

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  Self soothing

by Unknown

The goal with self-soothing skills is to comfort yourself emotionally by doing things that are sensually pleasant and, most especially, not harmful. At the same time, focusing your full attention on sensory inputs - on what you are physically experiencing in the moment (mindfulness) usually will get people outside of their own heads (and away from troubling thoughts, feelings, and impulses).

The skills and techniques listed below are a starting point only. Everyone has to find what works for them, and it may be things that are not on these lists.

With vision

   Buy one beautiful flower
   Make one space in a room pretty
   Light a candles and watch the flame
   Set a pretty place at the table, using your best things, for a meal
   Go to a museum with beautiful art
   Go sit in the lobby of a beautiful old hotel
   Look at nature around you
   Go out in the middle of the night and watch the stars
   Walk in a pretty part of town
   Fix your nails so they look pretty (even "real men" can do this)
   Look at beautiful pictures in a book (I have several photography books that are wonderful for this, one of which is just photos of children)
   Go to a ballet or other dance performance, or watch one on TV
   Be mindful of each sight that passes in front of you, not lingering on anything

With hearing

   Listen to beautiful or soothing music, or to invigorating and exciting music (many people recommend that country music be avoided, since the lyrics tend to be depressing). Classical can be very good, since there are no lyrics to trigger specific thoughts
   Pay attention to the sounds of nature (waves, birds, rainfall, leaves rustling) or listen to tapes of nature sounds (I use a whale song tape, and a rain forest tape)
   Sing your favorite songs
   Hum a soothing tune
   Learn to play an instrument
   Call 800 or other numbers to hear a human voice
   Be mindful of any sounds that come your way, letting them go in one ear and out the other

With smell

   Use your favorite perfume or lotions, or try them on in the store
   Spray fragrance in the air
   Light a scented candle
   Put lemon oil on your furniture
   Put potpourri in a bowl in your room
   Boil cinnamon
   Bake cookies, cake, or bread
   Smell the roses
   Walk in a wooded area and mindfully breathe in the fresh smells of nature

With taste

   Have a good meal
   Have a favorite soothing drink such as herbal tea or hot chocolate (no alcohol)
   Treat yourself to a dessert
   Put whipped cream on your coffee (or, if you're like me, your cereal, toast, ice cream, rocks, put whipped cream on almost anything and I'll eat it)
   Sample flavors in an ice cream store
   Suck on a piece of peppermint candy (or other flavors that you like - hard candy is recommended, though, since for many people soft candies can be triggering)
   Chew your favorite gum
   Get a little bit of a special food you don't usually spend the money on, such as fresh-squeezed orange juice
   Really taste the food you eat; eat one thing mindfully

With touch

   Take a bubble bath
   Put clean sheets on the bed
   Pet your dog or cat
   Have a massage (I think everyone should do this at least monthly, with a professional that you trust - there are people who specialize in therapeutic massage specifically to release body memories, etc.)
   Soak your feet
   Put creamy lotion on your whole body
   Put a cold compress on your forehead. Or wrap your face in a very warm, damp facecloth (wonderfully relaxing) - my kids and I have done this before dinners sometimes - it really calms everyone down
   Sink into a really comfortable chair in your home, or find one in a luxurious hotel lobby
   Put on a silky blouse, dress, or scarf (satin or velour is also great, even for men)
   Try on fur-lined gloves or fur coats in a department store (artificial furs, please)
   Brush your hair for a long time
   Hug someone
   Experience whatever you are touching; notice touch that is soothing

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  Self injury: Beyond the myths

© Deb Martinson

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 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 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.

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 speaks to intent and maiming the body is usually not the intent 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 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 unthinkably bad, 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 almost immediately brings their levels of psychophysiological tension and arousal back to a bearable baseline level. 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 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 typically range from early teens to early 60s, although they may be older or 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 can 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 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, easing 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 use 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, 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. Medical professionals who are unable to cope with their own feelings about self-harm have an obligation to themselves and their clients to find a practitioner willing to do this work. In addition, they are responsible for ensuring that the client understands the referral is due to their 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 may be 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 self 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.

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  Why do people deliberately injure themselves?

Subjective: What self-injurers say SI does for them
Miller (1994) and Favazza (1986, 1996). among others, discuss several possible motivations:

   Escape from emptiness, depression, and feelings of unreality.
   In order to ease tension.
   Relief: when intense feelings build, self-injurers are overwhelmed and unable to cope. By causing pain, they reduce the level of emotional and physiological arousal to a bearable one.
   Expression of emotional pain
   Escaping numbness: many of those who self-injure say they do it in order to feel something, to know that they're still alive.
   Obtaining a feeling of euphoria
   Continuing abusive patterns: self-injurers tend to have been abused as children. Sometimes self-mutilation is a way of punishing oneself for being "bad."
   Relief of anger: many self-injurers have enormous amounts of rage within. Afraid to express it outwardly, they injure themselves as a way of venting these feelings.
   Biochemical relief: there is some thought that adults who were repeatedly traumatized as children have a hard time returning to a "normal" baseline level of arousal and are, in some sense, addicted to crisis behavior.
   Obtaining or maintaining influence over the behavior of others
   Exerting a sense of control over one's body
   Grounding in reality, as a way of dealing with feelings of depersonalization and dissociation
   Maintaining a sense of security or feeling of uniqueness
   Expressing or repressing sexuality
   Expressing or coping with feeling of alienation

Miller also notes one explanation for why such a large majority of these patients are female: women are not socialized to express violence externally. When confronted with the vast rage many self-injurers feel, women tend to vent on themselves. She quotes the feminist poet Adrienne Rich:
"Most women have not even been able to touch this anger except to drive it inward like a rusted nail."
As Miller says, "Men act out. Women act out by acting in." Another reason fewer men self-injure may be that men are socialized in a way that makes repressing feelings the norm. Linehan's (1993a) theory that self-harm results in part from chronic invalidation, from always being told that your feelings are bad or wrong or inappropriate, could explain the gender disparity in self-injury; men are generally brought up to hold emotion in.
Objective: What the researchers have found
People who self-injure tend to be dysphoric -- experiencing a depressed mood with a high degree of irritability and sensitivity to rejection and some underlying tension -- even when not actively hurting themselves. The pattern found by Herpertz (1995) indicates that something, usually some sort of interpersonal stressor, increases the level of dysphoria and tension to an unbearable degree. The painful feelings become overwhelming: it's as if the usual underlying uncomfortable affect is escalated to a critical maximum point. "SIB has the function of bringing about a transient relief from these [high levels of irritability and sensitivity to rejection]," Herpertz said. This conclusion is supported by the work of Haines and her colleagues.
In a fascinating study, Haines et al. (1995) led groups of self-injuring and non-self-injuring subjects through guided imagery sessions. Each subject experienced the same four scenarios in random order: a scene in which aggression was imagined, a neutral scene, a scene of accidental injury, and one in which self-injury was imagined. The scripts had four stages: scene-setting, approach, incident, and consequence. During the guided imagery sessions, physiological arousal and subjective arousal were measured.
The results were striking. Subject reactions across groups didn't differ on the aggression, accident, and neutral scripts. In the self-injury script, though, the control groups went to a high level of arousal and stayed there throughout the script, in spite of relaxation instructions contained in the "consequences" stage. In contrast, self-injurers experienced increased arousal through the scene-setting and approach stages, until the the decision to self-injure was made. Their tension then dropped, dropping even more at the incident stage and remaining low.
These results provide strong evidence that self-injury provides a quick, effective release of physiological tension, which would include the physiological arousal brought on by negative or overwhelming psychological states. As Haines et al. say
Self-mutilators often are unable to provide explanations for their own self-mutilative behavior. . . . Participants reported continued negative feelings despite reduced psychophysiological arousal. This result suggests that it is the alteration of psychophysiological arousal that may operate to reinforce and maintain the behavior, not the psychological response. (1995, p. 481)
In other words, self-injury may be a preferred coping mechanism because it quickly and dramatically calms the body, even though people who self-injure may have very negative feelings after an episode. They feel bad, but the overwhelming psychophysiological pressure and tension is gone. Herpertz et al. (1995) explain this:
We may surmise that self-mutilators usually disapprove of aggressive feelings and impulses. If they fail to suppress these, our findings indicate that they direct them inwardly. . . . This is in agreement with patients' reports, where they often regard their self-mutilative acts as ways of relieving intolerable tension resulting from interpersonal stressors. (p. 70).
Herman (1992) says that most children who are abused discover that a serious jolt to the body, like that produced by self-injury, can make intolerable feelings go away temporarily.
Brain chemistry may play a role in determining who self-injures and who doesn't. Simeon et al. (1992) found that people who self-injure tend to be extremely angry, impulsive, anxious, and aggressive, and presented evidence that some of these traits may be linked to deficits in the brain's serotonin system. Favazza (1993) refers to this study and to work by Coccaro on irritability to posit that perhaps irritable people with relatively normal serotonin function express their irritation outwardly, by screaming or throwing things; people with low serotonin function turn the irritability inward by self-damaging or suicidal acts. Zweig-Frank et al. (1994) also suggest that degree of self-injury is related to serotonin dysfunction.
Those who self-injure may have personality characteristics that increase the likelihood of their self-injury. Haines and Williams (1997) found that self-mutilators reported more use of problem avoidance as a coping strategy and perceived themselves to have less control over problem-solving options. This feeling of disempowerment may in turn be related to the chronic invalidation many self-injurers have experienced.

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