Self-injury: a quick guide to the basics
If the whole concept of a disorder in which people deliberately inflict physical harm on themselves confuses you, or if you've been doing this for a while and never realized that it's recognized as a valid psychological problem all by itself, then this page is a good place to start learning about self-injury.
What self-injury is -- and isn't
You'll hear it called many things -- self-inflicted violence, self-injury, self-harm, parasuicide, delicate cutting, self-abuse, self-mutilation (this last particularly seems to annoy people who self-injure). Broadly speaking, self-injury is the act of attempting to alter a mood state by inflicting physical harm serious enough to cause tissue damage to your body. This can include cutting (with knives, razors, glass, pins, any sharp object), burning, hitting your body with an object or your fists, hitting a heavy object (like a wall), picking at skin until it bleeds, biting yourself, pulling your hair out, etc. The most commonly seen forms are cutting, burning, and headbanging. "Tissue damage" usually refers to damage that tears, bruises, or burns the skin -- something that causes bleeding or marks that don't go away in a few minutes. A mood state can be positive or negative, or even neither; some people self-injure to end a dissociated or unreal-feeling state, to ground themselves and come back to reality.
It's not self-injury if your primary purpose is:
||spiritual enlightenment via ritual|
||fitting in or being cool |
The sort of self-injury this site discusses is repetitive self-harm. People learn that hurting themselves brings them relief from some kinds of distress and turn to it as a primary coping mechanism.
Calling it self-mutilation often angers people who self-injure. Other terms (self-inflicted violence, self-harm, self-injury) don't speak to motivation. They simply describe the behavior. "Self-mutilation" implies falsely that the primary intent is to mark or maim the body, and in most cases this isn't so.
Why does self-injury make some people feel better?
There are a few possibilities, and the answer is probably a mixture of them. Biological predisposition, reduction of tension, and lack of experience in dealing with strong emotions are all factors.
It reduces physiological and psychological tension rapidly
A section of the causes page discusses this in more detail, but basically studies have suggested that when people who self-injure get emotionally overwhelmed, an act of self-harm brings their levels of psychological and 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.
This explains why self-injury can be so addictive: It works. When you have a quick, easy way to make the bad stuff go away for a while, why would you want to go through the hard work of finding other ways to cope? Eventually, though, the negative consequences add up, and people do seek help.
Some people never get a chance to learn how to cope effectively
We aren't born knowing how to express and cope with our emotions -- we learn from our parents, our siblings, our friends, schoolteachers, -- everyone in our lives. One factor common to most people who self-injure, whether they were abused or not, is invalidation. They were taught at an early age that their interpretations of and feelings about the things around them were bad and wrong. They learned that certain feelings weren't allowed. In abusive homes, they may have been severely punished for expressing certain thoughts and feelings. At the same time, they had no good role models for coping. You can't learn to cope effectively with distress unless you grow up around people who are coping effectively with distress. How could you learn to cook if you'd never seen anyone work in a kitchen?
Although a history of abuse is common among self-injurers, not everyone who self-injures was abused. Sometimes, invalidation and lack of role models for coping are enough, especially if the person's brain chemistry has already primed them for choosing this sort of coping.
Problems with neurotransmitters may play a role
Just as it's suspected that the way the brain uses serotonin may play a role in depression, so scientists think that problems in the serotonin system may predispose some people to self-injury by making them tend to be more aggressive and impulsive than most people. This tendency toward impulsive aggression, combined with a belief that their feelings are bad or wrong, can lead to the aggression being turned on the self. Of course, once this happens, the person harming himself learns that self-injury reduces his level of distress, and the cycle begins. For technical details on the possible role of serotonin, see the causes page and the psychopharmacology page.
What kinds of people 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 (or high-school students); 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. 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).
Aren't people who would deliberately cut or burn themselves psychotic?
No more 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.
Okay, then isn't it just another way to describe a failed suicide attempt?
NO. 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. And although some people who self-injure do later attempt suicide, 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.
Can anything be done for people who hurt themselves?
Yes. This site has a variety of self-help ideas, as well as some advice for family and friends of those who self-injure. Research into medications that stabilize mood, ease depression, and calm anxiety is being done; some of these drugs help people stop their self-harm. 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 stopped 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 who don't do it: 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 self-inflicted violence, the doctor should treat the wounds as they would treat non-self-inflicted injuries. Refusing to give 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 already feels. Although offering mental-health follow-up services is appropriate, psychological evaluations with an eye toward hospitalization should be avoided in the ER unless the person is clearly a danger to his/her own life or to others. In places where people know that 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.
Copyright 1998, Deb Martinson. Reproduction and distribution of this page is enthusiastically encouraged, especially distribution to medical personnel.
MHC is grateful for the information provided by Deb Martinson.