Dr. Angela Hanford
Do you know someone who intentionally cuts or burns themselves? Chances are that you do know someone who has engaged in self-harm behaviors, since it has been estimated that 14% to 17% of adolescents and young adults have reported engaging in self-injurious behavior (Whitlock, Eckenrode, & Silverman, 2006).
In one study of community adolescents, researchers discovered that 46.6% of participants reported engaging in non-suicidal self-injury (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007).From these and other studies, it is obvious that self-injury in teens is a major concern. What most people think of as self-injury is referred to as Non-Suicidal Self-Injury (NSSI) in the psychology community. NSSI is when an individual intentionally harms himself or herself in a manner that is not socially acceptable and does not have suicidal intent. From this point forward, NSSI will be referred to as self-injury.
When you hear the phrase self-injurious behavior, what is your initial reaction? You may have questions such as: Why would someone intentionally harm themselves? Are there any warning signs? How can I help?
Throughout this article we will examine these and other aspects of this very important and often misunderstood topic.
What Does Self-Injury Look Like?
Individuals who engage in self-injurious behavior may use one method or multiple methods. Often, in my experience, there may be an escalation in behavior from more superficial scratching or cutting to increasingly more severe harm.
Some researchers have found that self-injury can take on addictive features (Nixon, Clouter, & Aggarwal, 2002). This addictive component is something that I have seen in my own years of practice and makes self-injury more difficult to stop.
In terms of how people may injure themselves, the list is vast. One set of researchers found that the most frequently endorsed forms of self-injury were biting, cutting, hitting oneself, and burning (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007).
Punching objects, interfering with the healing of wounds, pinching oneself, pulling out hair for the purpose of hurting oneself, and breaking bones are more examples of forms of self-injury. Razors are often used for cutting, but other implements, such as a pencil sharpener blade, scissors, or paperclip may also be utilized.
Cutting is often done on the arms and legs (especially upper thighs). As you can imagine, it is fairly easy to find sharp objects. In fact, anything that can be used to cause pain can also be used for self-inflicted harm.
Why Would Someone Self-Injure?
It can be very difficult to wrap one’s mind around the idea that someone would intentionally inflict pain on himself or herself. In order for someone to come alongside someone who engages in self-harm and to offer support, this is an important question to answer.
There are actually a variety of reasons as to why someone may engage in self-injury. Common reasons for why someone might self-injure include:
- The need to soothe emotional pain that the individual is unable to effectively cope with in any other manner, such as depression and anger (e.g., Peterson, Freedenthal, Sheldon, & Andersen, 2008; Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007).
- Self-injury gives the individual something focus on rather than the emotions.
- There are likely also chemicals released in the brain in response to injury that lead to a soothing effect.
- The person who engages in self-injury may not know how to take care of emotions, but they do know how to take care of a physical wound.
- Self-injury can be a way of communicating emotional pain that the individual does not have the words to express.
- Self-injury could be an attempt for the individual to feel in control when they feel out-of-control (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007).
- Self-injury could also be a form of self-punishment. Perhaps a teen is angry at not making enough baskets at a game or not doing well enough on a test. Not only could both of these scenarios result in intense emotions that need soothing, but the teen may injure as a way to punish himself or herself for not being good enough.
- Sometimes those who engage in self-injury feel tension prior to injuring that is released when one self-injures (Nixon, Cloutier, & Aggarwal, 2002).
- When someone feels numb, self-injury can be a means of feeling something.
- There are times that self-injury can be used to manipulate others. However, it is important not to assume that manipulation is the reason or even the sole reason for self-harm.
- Someone may engage in self-injury as a way to gain attention or even to get a reaction from someone (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007). As with manipulation, it should not be assumed that the self-injurious behavior is simply attention seeking. Furthermore, it is important to ask why someone would want the attention, as they are likely not able to communicate in other, healthier, ways.
Regardless of the reason, self-injury is only a temporary relief. After engaging in the behavior, the individual typically feels intense shame and guilt. These feelings can lead to a cyclical pattern of self-harm. Therefore, treatment becomes key in helping someone develop tools to cope with the emotions that underly self-harm behaviors.
Risk Factors for Self-Injury
There are a variety of factors that seem to contribute to someone engaging in self-injury. Many of these factors, as may be obvious from the reasons why someone might self-harm, relate to emotions and emotion regulation.
Risk factors include:
- Mental illness, such as depression, bipolar disorders, anxiety, eating disorders, PTSD, borderline personality disorder, substance use disorders
- A history of abuse
- Low self-esteem
- Difficulty regulating emotions
- Internalizing emotions, especially anger
- Having a friend who engages in self-injury
Warning Signs for Self-Injury
Many people who engage in self-injury typically feel ashamed and, therefore, try to hide the fact that they hurt themselves. However, there are signs to watch for that may indicate someone is engaging in self-injury. Keep in mind that not all people who demonstrate these signs intentionally hurt themselves.
- Wearing long-sleeves during warm weather
- Avoiding places where wearing clothes that conceal is not acceptable or always wearing concealing clothes
- Continually wearing many bracelets/arm bands (to cover injuries)
- Refusing to wear a bathing suit (this may also be associated with body image issues)
- Having scratches, marks, or other accidental injuries at an unusual frequency that are quickly explained away (e.g., “The cat scratched me.”)
- Increased isolation that is often associated with depression
Research has demonstrated that self-injury is a risk factor for suicide attempts. For example, Klonsky, May, and Glenn (2013) discovered that self-injury was associated with suicide attempts in their participants and was second only to suicidal thinking.
Other factors that were associated with suicide attempts in this study were borderline personality disorder, depression, anxiety, and impulsivity. There have been many other studies that have found self-injury as being a leading risk factor for attempted suicide.
However, it should be noted that not all people who engage in self-injury also attempt suicide. In fact, many do not. Nevertheless, due to the increased risk for suicide, it is very important to discuss whether suicidal thoughts are present. If someone is thinking about suicide, it would be important to seek out immediate professional help, such as at a local hospital.
Ways You Can Help
Let us go back to an earlier question: What is your initial reaction when you hear that someone is intentionally hurting themselves? Self-injury can be scary, or you may feel helpless when learning that a loved one is engaging in self-harm behaviors. This is normal and completely understandable. Therefore, the first step is to deal with any of your own reactions.
This step is so important because you need to have the ability to remain calm and to be available for support when talking with someone who self-injures. What those who engage in self-injury need is a safe place to learn how to express feelings and to receive support.
Since self-injury can result in medical complications (e.g., infection), it is important to inform an adolescent’s caregivers. This disclosure, however, can create fear in the teen. Therefore, you may want to talk with the teen and ask him or her for input on how to tell the parents. Let the teen know that you are on their side and available for them, but you also have an ethical obligation to consider his or her safety.
There are responses that are not usually helpful when talking with someone who self-injures, such as:
- Requiring the teen to stop injuring immediately: Often when forced to stop the behavior, he or she will become more secretive and find better ways of hiding the injuries (e.g., cutting below the panty line). Instead, it is important to let the teen know that you are concerned and available to talk if needed. This being said, if the self-injury is more than superficial, immediate intervention may be needed in order to keep the teenager safe.
- Punishment for self-harm behaviors
- Discussing the injury with others (except for trained professionals)
- Making shaming remarks, as they typically feel a lot of shame anyway
- Not taking the self-injury seriously
Treatment for Self-Injury
Stopping self-harm can be very difficult, especially since this may be their only way to cope and ease emotional suffering. Self-injury often becomes a “friend,” the only one consistently there to ease emotional pain. Therefore, it is typical for people to relapse and to have strong urges to self-injure.
However, hope and healing is very possible. If you or someone you know is struggling with self-injury, it is time to seek out a competent therapist who understands and knows how to treat self-injurious behaviors.
Treatment may include: individual, family, and/or group psychotherapy. Medication may also be recommended.A therapist will help someone who self-injures learn how to cope with and express emotions in a healthy manner. In therapy, the individual will learn how to express emotions and connect with people in an emotionally vulnerable way.
In addition, it is important to remember that there is an underlying reason for the self-injury, such as depression, anxiety, or anger. A therapist will work with you or your loved one to find the appropriate approach for treating the underlying reasons for self-injury.
Seeking treatment is very important, and even lifesaving, for someone who engages in self-injury. Therefore, if you or a loved one is struggling with self-injurous behavior, please reach out for help. We are here to work with you on your path to healing!
Michael Hollander (2017): Helping Teens Who Cut, Second Edition: Using DBT Skills to End Self-InjuryPatricia McCormick (2000): CutSheri Van Dijk, MSW (2011): Don’t Let Your Emotions Run Your Life for Teens: Dialectical Behavior Therapy Skills for Helping You Manage Mood Swings, Control Angry Outbursts, and Get Along with Others
National Alliance on Mental Illness (NAMI): https://www.nami.org/learn-more/mental-health-conditions/related-conditions/self-harm
S.A.F.E. Alternatives – selfinjury.com
Klonsky, D.E., May, A.M., & Glen, C.R., (2013). The relationship between nonsuicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122 (1), 231-237.
Lloyd-Richardson, E.E., Perrine, N., Dierker, L., & Kelley, M.L. (2007). Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychological Medicine, 37(8), 1183-1192
Mayo Clinic. Self-Inury/Cutting. https://www.mayoclinic.org/diseases-conditions/self-injury/symptoms-causes/syc-20350950. Retrieved on 3/25/18
Muehlenkamp, J.J., & Gutierrez, P.M. (2004), An investigation of differences between self-injours behaivor and suicide attempts in a sample of adolescents. Suicide Life-Threatining Behaviors. 34(1), 12-23.
Nixon, M.K., Cloutier, P.F., Aggarwal, S. (2002). Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. Journal of the American Academy of Child and Adolesdent Psychiatry. 41(11), 1333-1341.
Peterson, J., Freedenthal, S., Sheldon, C., & Andersen, R. (2008). Nonsuicidal self injury in adolescents. Psychiatry (Edgmont), 5(11), 20-26.
Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious behav- iors in a college population. Pediatrics, 117, 1939–1948. doi:10.1542/ peds.2005-2543
*This information is about self-injury not associated with developmental disabilities (e.g., Autism).
“Autumn Love Signs”, Courtesy of Roman Kraft, Unsplash.com; CC0 License; “Cold Highway”, Courtesy of Amanda Sandlin, Unsplash.com; CC0 License; “Pink Orange Flower”, Courtesy of Saffu, Unsplash.com; CC0 License; “Aspen Tree in Flagstaff”, Courtesy of Peng Chen, Unsplash.com; CC0 License