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A friend confides in you that she deliberately cuts herself with a razor blade. What would your reaction be? Self-injury is little understood by most people. The idea of deliberately hurting yourself is seemingly incomprehensible, but for many of those who do exactly this, it is a survival tool, a coping mechanism that enables them to sustain their life through emotionally difficult times. For most of us, cutting or burning our own skin would be incredibly painful and almost impossible to carry out. For cutters, it is a strangely effective coping method for dealing with inner pain so overwhelming it must be brought to the surface (Strong 1998). Definition Self-Injury, also commonly known as self-harm; self-mutilation; self-abuse; and self inflicted violence, is defined as the deliberate harming or alteration of one's body tissue without the conscious intent to commit suicide. Integral to this definition are several key concepts. First, self-injury is an act done to the self. Second, it is done by the self. Third, it must include some type of physical violence. Fourth, self-injury is not undertaken with the intent to kill oneself. And fifth, it is an intentional act. Types of Self-Injury Favazza (1996) separates self-mutilation into two major groups. The first being culturally sanctioned self-mutilation, which is subdivided into rituals and practices, and the second deviant self-mutilation, which is subdivided into major self-mutilation, stereotypical self-mutilation, and superficial or moderate self-mutilation. It is the second group, deviant self-mutilation, and more specifically the subdivision of superficial or moderate self-mutilation, that is the subject of this research. Major self-mutilation acts, such as castration; amputation; and eye enucleation, are most commonly associated with psychotic states. They tend to occur suddenly, with major tissue damage and profuse bleeding. Stereotypic self-injury is repetitive and the pattern of acting out can be rhythmic. It is most commonly seen amongst the autistic, mentally retarded, and psychotic populations. The most typical behavior is that of head-banging. Superficial or moderate is the most frequently performed act of self-injury. The prevalence of self-injurious behavior is put in the range of 750 to 1,400 cases per 100,000 population. The most common methods of injury are cutting, burning, skin-picking, hair pulling (trichotillomania), bone-breaking, hitting, and interference with wound healing. Favazza (1996) has further subdivided superficial or moderate self-injury into three types: compulsive, episodic, and repetitive. Compulsive self-injury is repetitive and ritualistic and has multiple occurrences in a day. The most common behaviors are hair pulling (trichotillomania) and skin picking. Episodic self-injury occurs every so often and without the self-injurer identifying himself or her as a 'cutter' or 'burner'. It may be a symptom, or associated feature, of many disorders. Among them being anxiety, dissociative disorders, depression, and personality disorders. Episodic self-injury becomes repetitive when the self-injurer becomes overwhelmingly preoccupied with the behavior and identifies with being a 'cutter' or 'burner'. A repetitive self- injurer may describe himself or herself as being addicted to their self-harm. It is not the number of injuries that, therefore, marks the difference between episodic and repetitive self-injury, but rather the person's identity with their behavior. Repetitive self-injury is best considered an impulse control disorder, not otherwise diagnosed. Who Self-Injures? Self-injury cuts across the boundaries of race, gender, age, education, sexual preference, and socio-economic brackets. There is no 'typical' self-injurer, however, through the compilation of the traits of known self-injurers it is possible to build an image of the 'typical' self-injurer. A self- injurer is typically female, although recent statistics put the number of males and females who self- injures as roughly equal. Self-injury typically begins during adolescence, peaks during the twenties, and declines or disappears in the thirties. Many self-injurers also have histories, or current problems, of substance abuse, eating disorders, and compulsions (obsessive/compulsive or compulsive alone). They often lack the ability and skills to regulate their moods by other methods. Many have a history of being abused (physically, sexually, and emotionally), with a large proportion of the abuse starting in childhood. Commonly, people who self-injure have a history of psychological treatment through admissions to psychiatric hospital and/or in seeking therapy. Favazza and Conterio (1988) found that half their sample had received inpatient care, with a median of 105 days hospitalization, and two-thirds had received outpatient care, with a median of 75 sessions. There also appears to be a significant relationship between self-injury and the lack of social-support systems. Why Do People Self-Injure? The Purpose Self-Injury Serves The alteration or destruction of body tissue may be regarded on its surface (both literally and figuratively) as a morbid behavior on the one hand, and as a self-help behavior on the other (Favazza and Conterio 1988). We all have methods of coping with stress, whether it is emotional, physical or psychological. Coping is a behavior, which an individual utilizes to get through stressful, and difficult times as best they can. And sometimes the methods we use are extreme, perhaps excessive in comparison to the original stress. Self-injury is an example of an extreme method, but a method that, nonetheless, serves its purpose. Mentally ill self-injurers have an increased risk of suicide, although self-injury itself in not a failed attempt at suicide. It is frequently mistaken for a suicidal gesture, but there is a clear distinction between repetitive self- injury and suicide attempts. Self-injury is intended not to kill, but rather to relieve unbearable emotional pain and many survivors regard it, paradoxically, as a form of self-preservation (Herman 1992). The reasoning behind self-injury is diverse and by no means the same for all self- injurers. Self-injurers may give a single reason for their behavior, but, more commonly, their reasons are multiple and sometimes, on the surface, seemingly conflicting. Some of the more common purposes that self-injury serves are explored below. RELIEF FROM OVERWHELMING EMOTIONS is one of the reasons given most often for self-injury. The immense internal psychic pressure felt from overwhelming emotions can seem uncontrollable, frightening, and dangerous. People who self-injure have often not learned to identify, express, or release their emotions. Most have never developed the ability to feel and express emotions as others do. They may not have been allowed to show or release their true emotions. Yet their feelings still exist, whether they show them or not. They may have adopted self-injury as a strategy for getting relief from these intense feelings (Alderman 1997). The relief gained from these emotions is rapid, but temporary. The effectiveness of self-injury, at the moment, to provide relief and release is one of the reasons why self-injurers find it so difficult to stop. PHYSICAL EXPRESSION OF EMOTIONAL PAIN is one way for the self-injurer to provide evidence/confirmation of their psychological suffering. Self-injurers speak of their wounds and their scars as being a way to see the pain they feel inside. That by causing these injuries they are bringing their pain out to be seen and perhaps healed. Often, individuals who engage in self-injury tend to minimize or doubt their own internal experiences. Physically expressing the emotional pain allows them to have concrete evidence of intangible, amorphous, or indefinable emotions (Alderman 1997). Self-injury speaks loudly of the pain the individual feels long before they have the words to express it. UNREALITY, NUMBNESS, AND DISSOCIATION are experienced by many self-injurers. Dissociation is something that most of us have experienced, through such breaks in consciousness as daydreaming or driving past your exit from the motorway. Even though everyone dissociates to some degree at times, for some it is a defense mechanism, protecting them in the face of intolerable emotional pain. After a time, this too becomes intolerable, and self-injury may become a means for reducing, preventing, or ending a disturbing dissociative state. At times, the emotionally numb state may extend to physical anesthesia, so that severe injuries may be inflicted with a minimum of pain (Moskovitz 1996). Although we all dissociate, most of us do not fear that we will physically and/or psychologically disintegrate. What makes it different for self- injurers is that they feel they are shattering - falling apart. One woman uses the analogy of a magician taking a dollar and tearing it into many pieces. He waves his wand, mumbles some words and 'presto' the dollar is whole again. She says she feels like that dollar, ripped up into may pieces, she cuts and 'presto' she feels whole again. SELF-PUNISHMENT AND SELF-HATE may well be the simplest and most easily understood explanation of self-injury. Histories of childhood abuse (physical, sexual, and/or emotional) are represented in a high proportion of individuals who self-injure. Common with childhood abuse is the child erroneously blaming themselves for their abuse. Many children believe that they deserved everything they got, they somehow asked for it, and that they are innately bad. These lessons from childhood often remain and influence their treatment of themselves. They are unduly critical of themselves, leading to feelings of shame and blame, which then leads to self-punishment for their perceived transgression. Many self-injurers have been taught that many thoughts, feelings, and emotions that we take for granted, such as feeling angry and having needs are bad and deserve punishment. When these are aroused in them their self-hate is emphasized and they feel they have to pay. Many describe the letting of their blood, the essence of their life force, as getting rid of some of the badness. SELF-NURTURING may seem to be in conflict with the act of intentionally hurting oneself, but self-injury has a self-nurturing component for some individuals through the self-care they are able to give to themselves afterwards, and through the making on internal wounds external there is also an attempt to heal oneself. Feeling that they are alone and that no one cares is common with self-injurers. A gain from their injuries is the care they give to themselves. One self-injurer described it as 'an excuse to take care of and be gentle with myself'. Self-mutilation may also be therapeutic because of the symbolism associated with the formation of scar tissue; scar tissue indicates that healing has occurred. Thus, with a few strokes of a razor the self-cutter may unleash a symbolic process in which the sickness within is removed and the stage is set for healing as evidenced by a scar. The cutter, in effect, performs a primitive sort of self-surgery, complete with tangible evidence of healing (Favazza 1996). The Biology of Self-Injury Serotonin, a neural transmitter, is believed to be connected with impulsively and aggression. Using a blood platelet binding test, Simeon et al. (1992) measured serotonin activity. The results of their study were significant in reporting that the self-injurious group had more personality pathology, greater lifetime aggression, more antisocial behavior, and lower levels of serotonin activity (Favazza 1996). The use of SSRI (selective serotonin reuptake inhibitors) medications, such as Prozac and Zoloft, have indirectly contributed to the theory, that increasing brain serotonin levels may help reduce self-injurious behavior, by the results of people who take these medications. There is also a theory that endorphins, and specifically enkephalins, contribute to the 'addictiveness' some self-injurers describe. The thinking is that as endorphins function as natural narcotics or opiates in the body that self-injurers learn to associate their injuries with the positive feelings they get when the endorphins are released. There is some question to this theory as many self-injurers report little or no pain while injuring themselves. The Nature of Self-Injury Self-injury has been, and still is to a large degree, perceived by mental health professionals and people in general as repulsive, frightening, and senseless. It many times engenders reactions of anger and hopelessness by those who work with self-injurers. In great part, for these reasons, despite the relatively high prevalence of deviant self-injury, this behavior still remains somewhat mysterious. The professionals that the self-injurer turns to for help have largely ignored it. Although the 1990's has seen a large increase in the reporting of self-injury and research into the condition is increasing, it is still not well understood by professional mental health workers. SHAME AND SELF-INJURY are deeply related for most self-injurers. There appears to be a cycle connecting shame with self-injury. Often self-injurers feel a sense of shame, related to their past experiences, before they hurt themselves and after the act they feel shame about what they have done to themselves. This self-generating cycle often breeds secrecy about the behavior. The shame self-injurers feel and the fear of being judged by others leaves them isolated and this further perpetuates the self-injury cycle. The shame and embarrassment that is felt due to the self- injury can arise from different aspects of the self-injury. It can be affected by the physicality of the wound, the type of injuries that the individual engages in, the emotions that are experienced, sometimes a feeling of not being in control and vulnerability. This shame explains the excuses that are offered for the injuries, such as cat scratches, accidents in the kitchen, and so on. RITUALS IN SELF-INJURY can relate to the environment that self-injury is carried out in, the instruments the individual uses to cause the injuries, and the procedure that the individual will follow. The most highly ritualised behaviours are those of cutting and burning. Other behaviors, such as hair pulling; skin picking; and hitting oneself, tend to be less likely to follow a ritual. One of the reasons for this is that they are usually done without the use of any other instruments and tend to be more impulsive. Many self-injurers have specific places where they will carry out their self-injuring. The typically choose a place where they will be alone. This most likely is because alienation and isolation often-precipitate self-injury and these emotions are more likely to occur when the individual is alone. Many also arrange their environment in certain way, such as with the use of candles; burning incense; drawing curtains; and so on. If there was a pattern to the occurrence of childhood abuse, self-injurers may find themselves following this pattern with their self-injuring. The use of instrument, such as a single edge razor blade rather than a double edged one, is also important to many. If their instrument of choice is not available they may not engage in the self-injurious behavior until it is available. Many self-injurers have a procedure that they feel they must follow in performing their self-injury. It may involve laying out all the objects required to inflict the injuries and to then care for them, it may the use and arrangement of objects not to be used in the act of injuring, such as music and candles, or it may pertain to the order that everything is to be done in. IMPULSIVENESS AND SELF-INJURY share a complex, variable and unpredictable relationship (Alderman 1997). The results of research into the degree of impulsivity in self-injury have produced conflicting results. This may be due to the types of self-injurious behavior people choose to engage in and whether they have ritualised their behavior, rather than the nature of self-injury itself. Some types of self-injury are easier to perform, they require no particular objects, and are less conspicuous in their enactment, whereas other forms of self-injury require the use of instruments, are difficult to do 'anywhere', and may be entrenched in ritualisation. The difficulty of performing the latter forms of self-injury does not necessarily speak to the basic impulsive nature of the injuring. If the time, place, and availability of instruments were no problem, and the impulse to self-injury arose, the carrying out of the process of self-injury would be completed and would be an impulsive act, one with no preplanning. What Does and Doesn't Help People Who Self-Injure? Understanding why people hurt themselves is an important step toward healing. Equally important is understanding the components of good treatment: what works and what doesn't (Miller 1994). The reactions of family, peers, medical professionals, and others to self-injury have an impact on the self-injurer. Self-injury brings out a variety of feelings in people: shock, frustration, sadness, guilt, revulsion, anger, and fear, to name a few. When facing the physical evidence of the extent of the self-injurer's pain, people often realize their own helplessness in being able to stop the person self-injuring. It is not uncommon for this helplessness to be expressed as frustration and anger. Shame is an incredibly powerful emotion that will keep the self-injurer feeling negative about their self and their behaviors. Although self-injury is not the most typical behavior, there is nothing shameful about self-injuring. Through self-inflicted injuries they were able to cope and survive. The scars are testimonies to this survival. Shame and secrecy go hand in hand: openness and honesty are the antithesis of shame. The courage it took to survive the difficult time in their lives is something that can be a source of pride (Alderman 1997). Self-injury exists whether it is talked about or not. Keeping the silence reinforces the sense of shame that many feel about their SI and it maintains the isolation and alienation that can lead to SI. Whether you know what to say or not, letting the self- injurer know that you are willing to talk about SI is one way of providing support. An important factor in being able to provide support to someone who self-injures is being able to regulate your own reactions, keeping any negative and judgmental responses to yourself while providing support, although it is necessary to find a time and place where you can express these responses. It is important that if a self-injurer makes the decision to stop hurting themselves, they make it for themselves and not for someone else. Stopping is only possible when they are ready and they have developed other ways of coping. While most attempts to force, persuade, or suggest that a person stops self-injuring are based in a genuine desire to help and in caring for the self-injurer, if the self-injurer is not attempting to do so for their self failure is a most likely outcome. The self-injurer may also interpret your attempts for them to stop as being judgmental and demanding. This may serve to make them more secretive and to further break down communication. SI is a way to cope and if the self-injurer had another way to cope at that time most would use it. Trying to get someone to stop self-injuring is more about your needs than theirs. It is important that medical professionals, doctors in emergency departments; therapists; and other care providers, who give assistance are aware of their own limitations and take steps to increase their awareness, understanding, and education of self-injury. Whether these professionals have feeling of disgust, anger, empathy, fear, frustration, or any other reactive feeling, it is necessary for them to recognize and control these emotions while rendering their care. It is also important that medical professionals are weary of not overreacting. SI is rarely life threatening and seldom requires involuntary hospitalization. Although some medications are being tried with some success, there is no magic pill for stopping self-harm. Psychotherapy 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. References: Alderman, T. 1997. Scarred Soul. Oakland:New Harbinger Publications. Bass, E. & Davis, L. 1994. The Courage To Heal. New York:Harper & Row Publishers. Favazza, A.R. 2nd Ed. 1996. Bodies Under Siege. Baltimore:The John Hopkins University Press. Favazza, A.R. & Conterio, K. 'The Plight of Chronic Self-Mutilators'. Community Mental Health Journal, Vol 24:22-30, No 1, Spring 1988. Herman, J.L. 1994. Trauma and Recovery. New York:Basic Books. Linehan, M.M. 1993. Cognitive-Behavioural Treatment of Borderline Personality Disorder. New York:The Guilford Press. Martinson, D. 1999 Self-Injury: Beyond the Myths. selfinjury.webjump.com Miller, D. 1994 Women Who Hurt Themselves. New York:Basic Books. Moskovitz, R.A. 1996. Lost in the Mirror. Dallas:Taylor Publishing Company. Pattison, E.M. & Kahan, J. 'The Deliberate Self-Harm Syndrome'. American Journal of Psychiatry. 140:7, July 1983

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