From Dr. Tonja Krautter:

Understanding Self-Injury

I receive up to 10 calls per week from parents who are completely devastated to learn that their child is engaging in self-injurious behavior. Regardless of what it has been called (the bright red scream, the new-age anorexia, or the newest addiction) the practice of self-injury is on the rise. Shock, fear, anger, and confusion encompass parents every day when they are told that the child who they have tried their very hardest to protect from harm since birth is now choosing to harm herself. I use the feminine pronoun because it is more common for girls to self-injure than boys, however, this phenomenon does not limit itself to only one gender. Nor does it limit itself to a certain age, race, culture or socioeconomic status.

With a reported 2 million cases in the United States alone, this disorder has become rampant and affects a diverse population, including adults.  It is estimated that one out of every 200 teen girls and thousands of boys, between the ages of 13 and 19 regularly practice self-injurious behavior. The reasons behind the need to self-injure are complex and often neglected or misunderstood. Therefore, it is often kept as a “secret” from others, most likely resulting in the number of reported cases being significantly lower than the number of actual cases in our country.

The most common type of self-injurious behavior is cutting. However, this is not the only type. Others include burning, punching, head banging, kicking, scratching, and biting. More extreme, but much less common types of self-injury are injecting toxins into the body, breaking bones, and amputation of body parts.

It seems incomprehensible to most, especially parents, that a child would take a knife, razor blade, lighter or even a paper clip, thumb tack or fist to intentionally harm herself. Parents often ask, “What is my child trying to achieve?” The answer unfortunately is not a simple one. There are several reasons why kids self-injure. Therefore, the key in helping them to recover from this problem must start with an examination as to why they are doing it in the first place.  Let’s start by looking at the formal definition of self-injury as means to understand the general reasons behind this behavior. Self-Injury is the deliberate mutilation of the body or body part, not with the intent to commit suicide, but as a way of managing emotions that seem to painful for words to express.

The one common thread among the hundreds of patients I have seen is their inability to verbally express their emotions. Instead, they choose to physically express how they feel on their skin.  To illustrate this point, I introduce Amber to you.  Amber is 14 years old and began cutting herself 6 months ago.  She states, “When I cut, I want to draw blood. When I break, I want something to shatter. I want a trail that marks my pain.” Amber is looking for a way to prove to others and to herself that her pain is real. She has difficulty expressing her pain verbally, so alternatively, she chooses to express it physically. “Cutting became my cry for help when words could not do it for me. I wanted people to see how ugly I was, and how ugly I felt. I was tired of trying to explain how much I hurt on the inside. I wanted it to show on the outside.”

Amber is not alone. Those who self-injure are desperately trying to give voice to pain that has no words.  The origin of this pain is different for each individual. Therefore, investigating the specific reasons for self-harm is necessary for successful recovery.  These reasons may include tension reduction, self-punishment, a sense of belonging, and the desire to “feel alive” or conversely a way to “numb” their pain. Gaining this knowledge from your child may not be easy. In fact, most kids are unwilling to talk about this behavior and keep it a secret particularly from their parents.

There are several things that may indicate that a child is engaging in self-injurious behavior. One of the biggest red flags is when the child only wears long sleeves and pants especially in warm weather. Another red flag is when the child has multiple unexplained or justified injuries such as scratches, cuts or burns. Amber recalls how she attempted to hide her self-harm from people at school. She states, “My solution was long sleeves and pants and at hockey practice I cleverly used a sock which I said was a sweat band.” In addition, she remembers having to explain why she had scratches on her body. She recalls, “I even made up crazy stories about my cat for the occasional questions.”

Other warning signs may include low self-esteem, feeling easily overwhelmed, difficulty maintaining stable/healthy relationships, and difficulty functioning at school or home. Although all of these factors may be red flags, they are not in and of themselves direct indicators that self-injurious behavior is present in the child’s life.

Self-Injury is a coping mechanism. In contrast to what most people think, it is not a suicide attempt. In fact, many who self injure report that they engage in this behavior to avoid suicide. In their minds, they are taking care of themselves. This idea is counterintuitive, I know. Many wonder, “How can people who are inflicting self-harm honestly think that they are taking care of themselves by engaging in this behavior?” In fact, many of them are. Therefore, the first step in helping is understanding the person’s pain and recognizing that she is attempting to manage it.

As a parent, I know how scary it is to be confronted with something that you believe you have no control over finding a solution. It is even scarier when it is something that you do not understand. For most parents, self-harm fits both of these categories. The good news is that this problem is treatable. For highest success rates, treatment should begin as soon as possible due to its high habit forming potential with a therapist who has expertise in this area. During the treatment period, your love, support, patience, and encouragement will be invaluable to your child and will likely increase the success in her recovery.

Giving Voice to Pain that has No Words

In the past 13 years, I have worked with more individuals who self-injure than I can count. What was once thought of as a teenage phenomenon is now recognized as a struggle faced by woman of all ages. It may surprise you to know that the incidence of habitual bodily harm is approximately 1% in our country. With a reported 2 million cases in the United States alone, it is clear that this disorder has become rampant and affects a diverse population.

Perhaps you are reading this story because you self-injure or maybe you know someone that does. Since self-injury is becoming as widespread as substance abuse and eating disorders, it is not uncommon for most people to know someone who struggles with this problem. Although this difficulty is usually concealed rather than flaunted, it has received enough attention through the media to allow the topic to be “less taboo” and therefore more discussed. Perhaps these barriers were first broken down years ago when Hollywood stars such as Roseanne Barr and Johnny Depp as well as royal favorite, Princess Diana, admitted to the behavior. Fortunately, awareness of this problem has led to an increase in treatment intervention.

There are many reasons why people self-injure. If you are uncertain as to why you might be struggling with this problem think about the following. The most common reasons people self injure are (1) to cope with emotional distress, (2) to fill a void of emptiness, and (3) to seek attention. Often self-injury is a symptom of a more serious mental illness such as Post Traumatic Stress Disorder, Borderline Personality Disorder, Major Depression or Bipolar Disorder. If this is the case, treating the underlining illness is highly recommended as it will lead to improved psychological well-being and aid in the recovery process for self-injury.

The first step in recovery is acknowledging that there is a problem. This is not always easy to do. Although self-injury is much more understood today than it was in the past, it still comes with several myths and stereotypes. Unfortunately, admitting to the problem means risking these misconceptions.  For example, the fear of being labeled as “suicidal” commonly prevents identification of the problem. Individuals who self-harm do this as a way to cope with distressing emotions and not with the intent to commit suicide. In fact, many view self-injury as a way to self-nurture and prevent suicide. 

In addition, the fear of being referred to as a “cutter,” which then follows with labels such as “psycho,” “borderline,” “Goth,” or “emo,” commonly prevent identification of the problem. These labels often lead to disrespect and rejection from others. For example, Sarah is the CEO of a successful Silicon Valley company. She recently admitted self-injuring to her colleagues.  In turn, several of them questioned her leadership capability. Rhonda is the chief editor of a small town newspaper. Some of her colleagues noticed the multiple scars on her forearm, and immediately treated her differently. One eventually asked her how many times she tried to kill herself and if she would ever hurt anyone else?  When her boss found out, he too questioned her ability to perform job duties.

Once the problem is acknowledged, the next step is to find the motivation to stop. This may not be easy either since self-harm serves a purpose. First, you need to find out why you are doing it and then find alternative ways to fulfill the same need.  For example, if you self-injure for stress reduction, then think about healthier ways to relieve tension. The purpose of treatment is to eliminate the distress you are feeling. Having some sort of psychological distress in and of itself may be your motivation to stop. Many individuals resist treatment in fear that their coping mechanism will be taken away from them with no replacement behavior to help them feel better. This does not need to be the case. Alternative behaviors as well as unproductive thoughts can be identified in therapy sessions.

There is often a certain cognitive process that occurs for people who self-injure. It is a thinking style that focuses on extremes and places the person at high risk for low self-esteem. Since there is no grey area within the dichotomy, the individual sees herself as either all good or all bad. This leaves little room for partial gratification which leads to continual disappointment in life particularly in relationships with others. In addition, self esteem is highly dependent on external forces. Family, culture, and peer groups are all very influential in the person’s life causing her to be highly vulnerable when around these subsystems particularly if she is feeling misunderstood. For example, Andrea comments, “I often blamed myself for events that were outside of my control and rarely took responsibility for my own actions and their consequences.” Andrea’s motivation to be successful often came from the need to please others and not from within. In turn, she found herself constantly facing hurt and disappointment with herself and those around her. She self-injured to manage her feelings of “inner badness.”

It is important to investigate the way you think about yourself because these unproductive thoughts may lead to self-injury. You may experience thoughts of worthlessness or “inner badness.” You may then feel sad and “empty” inside. You may ruminate about death and dying and ponder the usefulness of your life. Sara comments, “I felt so empty inside that I often wondered if life were worth living. Self-injury helped me feel much more alive. I guess it just helped me to feel something.”

Lastly, you may experience great confusion, guilt, and shame for your actions.  This is another area to work on in treatment. Recognizing that you have a problem in and of itself is courageous. You can be proud of yourself for taking that first step in recovery. Seeking treatment shows great strength.  There is an addictive component to self-injury; therefore seeking help early will lead to higher rates of success. This is a behavior that can be stopped with help from a trained professional and one that can ultimately change your life in more positive ways than you might imagine.


Disclaimer

For those wanting further information on self-injury, we have taken the time to research and compile information below. Every effort has been made to ensure that the information collected below is complete and accurate. However each person’s situation presents unique issues and problems. Thus the ideas, procedures and suggestions below must be taken in context and considered in light of your own good judgment. This is intended as an informative guide for those desiring to understand, and to decide how best to deal with and get help for SI. The information offered herein is for educational purposes only. It is not intended as a substitute for consulting with a professional or with a physician. Obtain medical supervision and information regarding any suggestion that might affect your health or the health of your child, loved ones or family. Accordingly, individual readers must assume responsibility for their own actions, safety and health. We assume no liability or responsibility for any loss, injury or damage arising from any information or suggestions below. We hope you find it a helpful starting place to learning more about self-injury. We are not health professionals and while this information was compiled from various respected resources, it does not cover everything and we do not take responsibility nor endorse any of the websites or other referenced sources below. We do hope that they may be of use for further information and support.

Self-Injury Overview

Self-injury means to harm one’s own body on purpose, usually as a way of coping with emotional pain. Methods can include cutting, scratching or burning the skin, hitting things or the body, taking overdoses, ingesting harmful substances, ripping out hair and interfering with healing wounds. It is normally triggered by overwhelming feelings associated with depression and is used as a survival technique. Methods and severity vary from situation to situation; some people will require medical treatment and some people will be able to look after their injuries themselves. However injuries are treated though, they must be treated in some way and safety steps can be followed to reduce the risks, such as ensuring the blades are clean and not shared. It is important to realise that the severity of the injury is not necessarily linked with the pain being expressed. Due to the secret nature of self-injury, statistics are difficult to get hold of but it is thought that this issue more frequently affects females and often begins in adolescence. More detailed information on self-injury can be found below.

What is self-injury?

Possibly the most important thing, and certainly the most misunderstood thing about self-injury is that people battling amid these circumstances are doing so in order to live, not die. While there is obviously a link between self-injury and suicide and one may lead on from the other, the two are separate events and many who self-injure, use it as a survival technique.

Self-injury is described as the act of deliberately harming one’s own body. Cutting is thought to be the most common form of self-injury but other types of harm include burning or scratching the skin, hitting things or the body, taking overdoses, ingesting harmful substances or ripping out hair. Often, somebody who hurts themselves will use particular methods and focus on particular parts of the body.

It is also really important to recognise that the severity of the self-injury is not always linked to the severity of that person’s emotional pain. Some people require hospital treatment, some don’t and others are interchangeable and there are a multitude of reasons why people harm themselves in the particular way they do. Also, if someone is harming themselves over a long period of time, they may find they get ‘used to’ their method and that this stops achieving what it needs to so they may injure themselves differently or more severely.

Why do people harm themselves?

Self-injury is normally triggered by low self-esteem, self-hatred, anger, grief or other feelings associated with depression. Every person’s experience is different however and it would be wrong to put restrictions on reasons why. However, the most widely accepted idea is that self-injury offers a release of pent-up emotions that the person does not believe can be achieved in another way. Another suggestion is the idea of needing to exact punishment on oneself, perhaps for not being good enough.

Can the risks be reduced?

While it may seem a strange statement, if you are injuring yourself, you need to be safe. Cuts can become infected, especially if they have not been made with a clean instrument. Caring for injuries is very important, although interfering with healing wounds is a form of self-injury in itself. There are various kinds of dressings available which enable faster healing or reduced scarring and some types of dressings can be specific to the kinds of injuries sustained, i.e. for weeping wounds. Sharing cutting implements also seriously increases the risk of a large number of infections, including HIV.

If an injury is particularly serious, medical help really needs to be sought and always needs to be sought if you have taken an overdose.

Who self-injures?

Anybody could be affected by self-injury, although various surveys suggest that it is more common in females and often begins in adolescence. However, as is the nature of this situation, it is very difficult to gather statistics. Far from attention seeking, which is another misconception, many people suffer in silence.

According to the Secret Shame website (referenced in our Self-Injury Links section), it is estimated that 1000 per 100,000 (1%) of Americans self-injure. And according to a BBC Health article (referenced also in our link section), 10% of medical admissions in the UK are the result of self-injury.

Is there help available?

There are various kinds of help available for people in this situation.

Should a self-injurer want to seek professional help, there are various kinds of therapies known to be useful such as psychotherapy, hypnotherapy or Cognitive Behavioural Therapy (CBT), where the sufferer would work with a mental health professional to overcome this problem. This is useful in terms of receiving long-term support, hopefully figuring out root causes and also for maintaining a level of control of the treatment. We have listed several websites which offer support to people who are affected by self-injury including alternatives to self-injury that people have found helpful and forums where people can communicate with people in similar situations and express their feelings in a safe space rather than suffering alone.

Whether a self-injurer wants to seek medical help or not, many people in recovery have found other ways to deal with their pain than injuring their bodies. One idea is to hold an ice-cube in your hand in order to feel pain without damaging yourself. For a cutter who relies on seeing blood, red food colouring could be added to the water. Some people find drawing on themselves with red pen (washable) can be helpful, or ‘hurting’ a drawing of themselves. Others find that the sting of pinging an elastic band against their wrist works for them (although there is risk of bruising with this) or punching a pillow (ensuring that it is against a soft surface). It can be very difficult to change self-injuring techniques and sometimes doing other things can feel insubstantial but they are a less harmful ways of expressing pain. There are also suggested distraction techniques such as writing feelings down or listening to loud music.

If you find that somebody close to you is injuring themselves, the most helpful thing to do is give them space to talk if they want to. Offering acceptance and not judging their behaviour, even if you can’t understand it, is essential. It won’t do either of you any good to try and force them to stop; controlling the compulsion to injure themselves will come from them when they are ready.

Sources

Both of the following have been particularly useful in guiding the writing of this piece:

BBC Health (a comprehensive overview of self-injury)

NHS Direct (another medical based overview of self-injury)

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