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Old 02-20-2003, 09:05 PM
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Self-Injury

By: Andrew Levander, MFT

You'll hear it called many things -- self-inflicted violence, self-injury, self-harm, Para suicide, 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 perceived intolerable mood state by inflicting physical harm serious enough to cause tissue damage to the body.

There are many methods a self-injurer may use:
  • The most common is cutting (using razor blades or broken glass, etc.)
  • Burning
  • Scratching
  • Picking
  • Interfering with wound healing
  • Head banging
  • The breaking of bones

The reasons why someone self-injures are numerous and each time it is done, it does not necessarily have to be for the same reason. Some of the reasons are:
  • Relief from psychological pain
  • Release of mounting tension
  • Inability to feel
  • Feeling too much
  • Inability to handle any kind of feeling-good or bad
  • Wanting to feel something
  • Expressing anger
  • And sometimes self-injury is even used for getting attention-although in the majority of cases this is not true

Research

Researchers in the field and study of self-injury have for many years looked at the classification and types of self-injurious behaviors so that the clinical underpinnings of self-injury could emerge to best meet the therapeutic needs of the self-injurer.

Kahan and Pattison (1984; Pattison and Kahan, 1983) tackled these taxonomic problems. They began by identifying three components of self-harming acts: directness, lethality, and repetition.

Directness

Refers to how intentional the behavior is; if an act is completed in a brief period of time and done with full awareness of its harmful effects and there was conscious intent to produce those effects, it is considered direct. Otherwise, it is an indirect method of harm.

Lethality

Refers to the likelihood of death resulting from the act in the immediate or near future. A lethal act is one that is highly likely to result in death, and death is usually the intent of the person doing it.

Repetition

Refers to whether of not the act is done only once or is repeated frequently over a period of time It is defined simply by whether or not the act is done repeatedly.

Is Self Injury An Addiction?

Although self-injury may temporarily alleviate unwanted thoughts and or feelings, self-injurious behavior happens in the absence of healthy relationships with people. As a coping strategy, self-injury interferes with intimacy, educational successes, creativity and a person’s health and wellness.

Self-injury is not seen as an addiction, as the self-injurer is not viewed as powerless, however, self-injury is addiction-like, in that people engage in the repetitive or compulsive behaviors despite the consequences. The long-term goal in therapy is to create a master list of creative and relationally based alternatives that the self-injurer can utilize when the urge to act upon her/himself arises. It is important to note that children, adolescents and adults do stop injuring; they are all people in need of consistent, relationship-oriented support, nurturance and guidance.

Some of the Facts

Self-harm isn't a failed suicide attempt

Sometimes people injure themselves because they want to die. But often its more about staying alive. People may hurt themselves to help them get through a bad time. Its a way to cope.

People self-harm in different ways

Some cut their arms or legs; others bang or bruise their bodies. Self-harm also includes burning, scratching, hair pulling, scrubbing, or anything that causes injury to the body. Some people take tablets, perhaps not a big overdose, but enough to blot things out for a while.

It doesn't mean you're crazy

All sorts of people self-injure, even people in high-powered jobs. It's a sign that something is bothering and upsetting you, not that you are mad.

Lots of people self-harm

You may not have met anyone else who self-harms and may even think you are the only one who does it. There's a lot of secrecy about self-harm. But millions of people cope in this way.

It's not "just attention-seeking"

People self-harm because they are in pain and trying to cope. They could also be trying to show that something is wrong. They need to be taken seriously.

It can happen once, or many times

Some people attempt suicide or hurt themselves just once or twice. Other people use self-injury to cope over a long time. They might inure themselves quite often during bad times.

People do stop self-injury

Many people stop self-injury (when they're ready). They sort their problems out and find other ways of dealing with their feelings. It might take a long time and they might need help. But things can get better.

Other things can be 'self-injury' too

Things like starving, overeating, drinking too much, risk-taking, smoking and many others are also types of 'self-injury'. Some coping methods (like burying yourself in work) may be more acceptable, but can still be harmful.

Definitions of moderate/superficial self-injury:

Perhaps the best definition of self-injury is found in Winchel and Stanley (1991), who define it as:

...The commission of deliberate harm to one's own body. The injury is done to oneself, without the aid of another person, and the injury is severe enough for tissue damage (such as scarring) to result. Acts that are committed with conscious suicidal intent or are associated with sexual arousal are excluded.

Malon and Berardi (1987) summarize the process they believe underlies self-injury:

Investigators have discovered a common pattern in the cutting behavior. The stimulus...appears to be a threat of separation, rejection, or disappointment. A feeling of overwhelming tension and isolation deriving from fear of abandonment, self-hatred, and apprehension about being unable to control one's own aggression seems to take hold. The anxiety increases and culminates in a sense of unreality and emptiness that produces an emotional numbness or depersonalization. The cutting is a primitive means for combating the frightening depersonalization.

Incidence & onset

Experts estimate the incidence of habitual self-injurers is nearly 1 % of the population, with a higher proportion of females than males. The typical onset of self-harming acts is at puberty. The behaviors often last for 5-10 years but can persist much longer without appropriate treatment.

Background of self-injurers

Though not exclusively, the person seeking treatment is usually from a middle to upper class background, of average to high intelligence, and has chronic feelings of low self-esteem. Nearly 60% report physical and/or sexual abuse during his or her childhood. Many report (as high as 90%), that they were discouraged from expressing emotions, particularly, anger and sadness.

Behavior patterns

Many who self-injure use multiple methods? Cutting arms or legs is the most common practice. Self-injurers may attempt to conceal the resultant scarring with clothing, and if discovered, often make excuses as to how an injury happened. A significant number are also struggling with eating disorders and alcohol or substance abuse problems. An estimated one-half to two-thirds of self-injurers have an eating disorder.

Reasons for behaviors

Self-injurers commonly report they feel empty inside, over or under stimulated, unable to express their feelings, lonely, not understood by others and fearful of intimate relationships and adult responsibilities. Self-injury is their way to cope with or relieve painful or hard-to-express feelings and is generally not a suicide attempt. But relief is temporary, and a self-destructive cycle often develops without proper treatment.

Dangers

Self-injurers often become desperate about their lack of self-control and the addictive-like nature of their acts, which may lead them to true suicide attempts. The self-injury behaviors may also cause more harm than intended, which could result in medical complications or death. Eating disorders and alcohol or substance abuse intensify the threats to the individual’s overall health and quality of life.

Diagnoses

Self-injurious behavior can be a symptom of several psychiatric illnesses: Personality Disorders (esp. Borderline Personality Disorder); Bipolar Disorder (Manic-Depression); Major Depression; Anxiety Disorders (esp. Obsessive-Compulsive Disorder); as well as psychoses such as Schizophrenia.

Evaluation

If someone displays the signs and symptoms of self-injury, a mental health professional with self-injury expertise should be consulted. An evaluation or assessment is the first step, followed by a recommended course of treatment to prevent the self-destructive cycle from continuing.
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Old 02-20-2003, 09:06 PM
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Treatment

Self-injury treatment options include outpatient therapy, partial and inpatient hospitalization. When the behaviors interfere with daily living, such as employment and relationships, and are health or life threatening, a specialized self-injury program with an experienced staff is recommended.

The effective treatment of self-injury is most often a combination of medication, cognitive/behavioral therapy, and interpersonal therapy, supplemented by other treatment services as needed. Medication is often useful in the management of depression, anxiety, obsessive-compulsive behaviors, and the racing thoughts that may accompany self-injury. Cognitive-behavioral therapy helps individuals understand and manage their destructive thoughts and behaviors. Contracts, journals, and impulse control logs are useful tools for regaining self-control. Interpersonal therapy assists individuals in gaining insight and skills for the development and maintenance of relationships. Services for eating disorders, alcohol/substance abuse, trauma abuse, and family therapy should be readily available and integrated into treatment, depending on individual needs.

In addition to the above, successful courses of treatment are marked by 1) patients who are actively involved in and committed to their treatment, 2) aftercare plans with support for the patient’s new self-management skills and behaviors, and 3) collaboration with referring and other involved professionals.

When someone You Care About Is a Self-Injurer…

Someone you care about has entrusted you with information about his or her self-injury, or maybe you've seen it unwittingly. However you found out it is important to pay attention to self-injury in a helpful way. Here are some guidelines for dealing with SI in a friend or family member.

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 probably not cutting, burning, hitting, or scratching 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 self-injure to be dramatic, to annoy others, or to make a point.

Educate yourself

Get as much information as you can about self-injury in general. Find books that present the voice of self-injurers talking about what they do and why -- it lets you inside the mind of people who SI. Some selections that are particularly valuable are Bodily Harm, by Karen Conterio and Wendy Lader, PhD. Cutting by Steven Levenkron, and The Scarred Soul by Tracy Alderman, PhD.

Understand your feelings

Be honest with yourself about how self-injury makes you feel. Don't pretend 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 and do your best to not say anything like "My therapist says you should..." Therapy is a tool for self-understanding, not for getting others to change.

Be supportive without reinforcing the behavior

It's important that your child know that you can separate who they are from what they do, and that you love them independently of their behavior. Be available as much as you can be. Set aside your personal feelings of fear or revulsion about the behavior and focus on what's going on with the person.

Some good ways of showing support include:

· Attend to 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. You can't be supportive of someone if you can't be reached.

· 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 SI is to be consistently caring, so that helping the person take care of her/himself after they injure is nothing special or extraordinary.

· Provide distractions if necessary. Sometimes just being distracted (taken to a movie, on a walk, out for ice cream; talked to about things that have nothing to do with self-injury) can work wonders. If someone you care about is feeling depressed, you can sometimes help by bringing something pleasant and diverting into their lives. This doesn't mean that you should ignore their feelings; you can acknowledge that they feel lousy and still do something nice and distracting. (This is NOT the same as trying to cajole them out of a mood or telling them to just get over it -- it's an attempt to break a negative cycle by injecting something positive. It could be as simple as bringing the person a flower. Don't expect your efforts to be a permanent cure, though; this is a simple improve-the-moment technique.)

· If you live apart from the person you're concerned about, offer physical safe space: "I'm worried about you; would you come sleep over at my house tonight?" Even if the offer is declined, just knowing it's there can be comforting.

· Try not to 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 nonjudgmental) can be helpful. Spontaneous acts of kindness ("I saw this flower at the store and knew you'd love to have it") work wonders.

Take care of yourself

It sounds like hard work, and it is. If you try to be completely supportive to someone else 24/7, you're going to burn out (and they won't have any incentive to change). You have to find ways to be sure your needs are being met. Take a break from it when you need to. When setting limits, remember that as much as you love someone, sometimes you're going to need to get away from them for a while. Tell the person that sometimes you need to recharge and that it doesn't affect your love for him/her.

The balance here is tricky, because if you make yourself more and more distant, you might get a reaction of increasing levels of crisis from the other person. If you let them know that they don't have to be about to die to get love and attention from you, you can take breaks without freaking the person out. The key is developing trust, a process that will take some time. Once you prove that you are someone who isn't going to go away at the first sign of trouble, you will be able to go away in non-crisis times without provoking a crisis response.
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Old 02-20-2003, 09:08 PM
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Ultimatums do NOT work. Ever

Loving or caring about someone who injures her/himself is an exercise in knowing your limitations. No matter how much you care about someone, you cannot force him or her to behave, as you'd prefer him or her to. In nearly two years of running the bodies under siege mailing list, I have yet to hear of a single case in which an ultimatum worked. Sometimes SI is suppressed for a while, but when it inevitably surfaces it's often more destructive and intense than it had been before. Sometimes the behavior is just driven underground.

One person I know responded to periodic strip searches by simply finding more and more hidden places to cut. Confiscating tools used for SI is worse than useless -- it just encourages the person to be creative in finding implements. People have managed to cut themselves with plastic eating utensils. Punishments just feed the cycle of self-hatred and unpleasantness that leads to SI. Guilt tripping does the same. Both of these are incredibly common and both make things infinitely worse. The major fallacy here is in believing that SI is about you; it almost invariably isn't (except in the most casual ways).
Accept your limitations.

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 SI 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.

Self-injury--The Basics

If the whole concept of a disorder in which people deliberately inflict physical harm on themselves confuses you, well, welcome to the first problem in helping the self-injurer.

There are an estimated 2-4% or 1-3 million people in our population that engages in repetitive low lethality self-injury. About the same percentage as schizophrenics.

For this population there are only a handful of identified experts dedicated to treating this population of sufferers.

What self-injury is--and isn't

You'll hear it called many things -- self-inflicted violence, self-injury, self-harm, Para suicide, 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 head banging.

"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.

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 whom 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. 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?
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Old 03-07-2003, 02:29 PM
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Self-injury - 'older' person

Hi - I am 45, female and I started self injuring at the age of 31, which is pretty unusual. I have stopped for months at a time, but right now I can't (won't?) even go a week.
I have been in every kind of therapy there is (I think) and I am starting with a new therapist who has said that I cannot injure and stay in treatment with her. She says if I was just doing scratches or things that didn't require medical attention, it would be different, but I self-injure seriously enough to always need a trip to the ER.

Anyone out there that can help? I know "I" am the only one who can stop me, but I've been thru so many good treatments and I keep relapsing.

Being laid off this past November didn't help. I am functional and have always worked. The market is tough right now.

DonnaSue
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Old 03-07-2003, 03:08 PM
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DonnaSue,

Don't ever give up hope. I can remember saying the same thing as you have. "I've tried everything and I can't make it go away." Mine went away when I was the most hopeless and helpless.

Mine was emotional pain. Severe emotional pain that I had carried with me my entire life. It's gone now. I found the answer after I tried every kind of therapy and self help that exsisted.

I don't know if you believe in a Higher Power, but mine saved me. I finally had to surrender and let Him take over. We are not finished yet, but the difference is huge for me. It's never too late and you're never too old. I was close to 40 when all the changes started taking place in my life. It took about 5 years for God to show me all the garbage I had hidden inside. There is a reason for everything and an answer to everything. We just have to find it.

Hugs,
MG
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Old 03-07-2003, 03:32 PM
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Self-injury

Thanks for writing MG - I guess the part I am missing is that a lot of me doesn't WANT to stop. The rational part of me knows I should.
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Old 03-07-2003, 06:20 PM
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I can understand that DonnaSue.

What I discovered(and I'm not finished yet) is that there was a hidden reason for everything I was doing. It was when I dicovered the reasons that I was able to let go of the addictions that were connected to them.

What have you discovered about yourself and the reasons you self injure? What was happening in your life when you began coping this way?

Hugs,
MG
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Old 07-21-2004, 03:20 PM
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Old 07-21-2004, 05:54 PM
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mg,

you always have such good posts! does self talk help "mutilation urges"? ive not done this since a few months ago, and i havent done it "for attention" since about 4 years ago. i was very disturbed to find that the urges remain and i tend to do it because i get feeling out of control/generally nuts and then i get going and it becomes a bit of a compulsion. i have more trouble with it it seems when im not doing it LOL if that makes sense.

my theory on it is that when i was super active in mutilating (bruising, scratching, cutting) i didnt have a clue that i was mentally unstable. then once i got into therapy i didnt want to stop and the whole concept of being crazy intrigued me and thats when i did it for attention. now that ive been "clean" from mutilation and am very well aware of my mental illnesses i find i cant quite shake the urges. i sometimes have suicidal thoughts which dont really have to do with the mutilation, but knowing that im capable of mutilation just makes it all the more difficult to resist acting on my feelings.

im a happy person, but the thoughts of mutilation/suicide pop up from some sick place and sometimes i dont feel like i can control myself. is that just compulsion? part of me thats tired of being good? i dont know, but am hesitant to tell my therapist about feeling suicidal because generally im not. theres a few moments when i impulsively feel i could fling myself from a building or shoot myself but its not really how i feel. is that explaining it well?

thanks,

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Old 07-22-2004, 06:13 PM
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Hi Dotcom, This might not be the same but, I feel it is close. I had the same issues with the drinking and hating myself. I knew they were bad for me but, I didn't want to give them up. Once I gave them up I missed them. Heck, at times I still miss that life. How can we miss something so terrible. We all sound like giving and caring people when it comes to others. Most of my self abuse was verbal,but, there were a few times I came close to just hitting myself. Then I tried to kill myself. How, could I want to go back to being drunk and undependable, or like you said, how could you want to go back to hurting yourself? Do you sometimes feel you deserve this type of treatment? I wouldn't let someone else, do it to me, but, I think it is OK to do it to myself? I want to commend you for being so open and honest. You are helping me to be more open. I really believe what MG says, This is part of the process. Identify, feel the pain, understand and take the steps to deal with it. As long as we keep these things shameful secrets, they will remain just that.

"Recovery ain't no highway"
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Old 07-22-2004, 06:42 PM
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thank you for your reply don. i can relate to what you posted. i genuinely care about other people now that im clean from meth and other substances. i am beginning to value myself but theres that part of me that despite how much i love myself, wants to destruct. the mutilation gave me confidence. like the drugs did, only its not a drug. its not that i feel i deserve it so much, but that i like it. so i guess i get pissed like when i couldnt use and was still in using mode, i want what i want when i want it. it gave me a good feeling. i suppose with the control feeling comes other good feelings, but its more about pleasure than control which i dont like to say because it does not sound right but it is what it is. it really helps to be honest about it. you are right. right now, its not so much about using its about these mental illnesses and issues that i really need to get out on the table. there will be a stigma attached im sure and that is something i dread but unless i let go of that dread i will probably drive myself to the edge. i wont lie, i am doing well in terms of sobriety, but i feel very much like if i dont do something quick that i will never do anything about this stuff. do you know what i mean?

hugs,

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