Self-Injury: It’s time to stop judging the behavior and start understanding the causes
by Sara G. Stephens
In his early teens, Alex started intentionally breaking and pulling out his teeth. He recalls using a hammer and chisel one day to split his upper front tooth in half. His mom saw him and broke down in tears. That was enough to make Alex stop for a while. But not for long. The urge was too strong, and he soon found ways to hide his behavior, like breaking back teeth. “I even once pulled out a bottom front tooth using pliers and just put the tooth back in its place using glue,” Alex says.
Leaving home gave Alex the freedom to “have a field day” pulling out teeth. Soon he was wearing dentures. Now Alex is in his mid-thirties and describes his life as “normal.” He is a successful business owner and married with two kids. Alex reports having slowed down on his unusual habit, but it’s not for lack of the urge. “It’s because I only have a few teeth left and the thought of not having any teeth left to damage scares me,” he confides.
“I can’t really explain why I do it, other than to say I get some kind of enjoyment out of it,” Alex (not his real name) admits. “I know it’s wrong and it makes me ashamed, but sometimes I can’t resist the urge.” He is clear on the point that the urge to harm does not extend beyond his teeth or to other people, and he has never experienced suicidal thoughts.
Alex may be successful by all visible social standards, but the secret he harbors darkens any real potential for true happiness. Alex has never been treated or counseled for his self-harming behavior. He says he would like some answers as to why he is the way he is so that he might gain some peace by understanding the causes for his behavior, even though he believes “it’s probably too late for me to get help.”
Self-Injury: What We Know
Alex suffers from NSSI, Non-Suicidal Self-Injury, also referred to as self-injury (SI) or self-harm. In brief, SI is defined as “the deliberate and direct destruction of one’s body tissue without suicidal intent and not for body modification purposes,” according to sioutreach.org. The most common methods of self-injury include cutting, burning, scratching, and bruising, but can extend to any manifestation of intentional self-harm, including, but not limited to, biting, ingesting or embedding foreign objects into the body, hair pulling, and interfering with the healing of wounds, says sioutreach.org.
The site reports that 14 to 24 percent of youth and young adults have self-injured at least once. Twenty-five percent of these individuals have self-injured many times. “Some studies have found even higher percentages if they provide comprehensive checklists of the different types of possible self-injury methods or if they advertise their study as one about self-injury,” the site reports. Four percent of adults occasionally self-injure; males and females report similar rates of self-injury.
Although SI can start at any age, it’s generally known that most of these behaviors initiate during the teenage years, with the most common age of onset being early adolescence. “More than half of young adults who have engaged in self-injury recall starting at this time,” states sioutreach.org. “However, slightly less than a quarter recall starting before age 12… Many people who start self-injuring in their teens continue into adulthood, while others may start self-injuring as adults.”
Although statistics such as these are an important tool for social recognition of a problem, SI statistics are notoriously hard to peg, partly because so many instances of SI go unreported. There is a shame factor associated with self-harming, strongly tied to the public’s inability to sympathize, much less empathize, with those who engage in these behaviors.
“There’s a huge stigma attached to self-harming, which is understandable, as the behavior can be quite alarming,” says Lori Vann, MA, LPCS, a Carrollton, Texas-based SI counselor and expert, who is writing a book on the topic. “The big deal is secrecy. Not being accepted,” Vann explains. “I’m not saying SI should be the norm or viewed as okay to do, but the reason many self-injurers start is they can’t express their emotions in a usual manner anyway. In their minds, they don’t have a right to their emotions—and that’s where you get to their emotional abuse. Their rationale is, ’If I can’t verbalize my feelings, I have to take it inward.’“
Vann adds that, because self-harmers can’t display their cuts or injuries to others, they remain in “shame mode.” Often, attempts to confide in someone or simply being outed are met with assumptions of, “You’re just doing it to get attention,” or, “If it’s a problem, why don’t you just stop doing it?” People are quick to judge and to resort to name-calling. Family members respond with accusations. Even doctors contribute to the negative response. “Many of my clients have doctors give them negative comments, saying things like, ‘Just stop it. What’s your problem?’” Vann reports.
“Katy” understands firsthand the stigma associated with SI. As a public-relations associate for a prominent Houston-based organization, she, like Alex and every self-harmer interviewed here, requested an alias be used in her commentary. Katy has experienced SI for many years. “I never knew it was a symptom or even had a name like ‘self-injury,’ because nobody was talking about such things when I was growing up,” Katy says. “It wasn’t until I was in my 20s and saw the indie film Thirteen with Evan Rachael Wood cutting herself that I realized there must be other people who participated in these types of dangerous coping skills.”
In 2010, Katy’s favorite singer, Pink, released the song “F**kin’ Perfect,” which was promoted by the organization To Write Love On Her Arms (www.twloha.org). “I researched them and saw all the wonderful things they do by spreading awareness and hope for SI,” Katy says. “They also do a great concert series throughout the country and were recently here in Houston at the House of Blues. Ironically, years before I knew of To Write Love On Her Arms, I got a tattoo on my wrist that says ‘Love.’”
Katy sums up her feelings about TWLOHA as such: “I love that their vision encourages community and hope in order to replace secrets and silence. Donating my time and dollars to TWLOHA means somebody out there is able to get help, hope and treatment.”
FROM THE SELF-HARMERS: Causes
With any illness, getting to a cure begins with understanding the cause. SI is no different. Although many self-harmers are not fully aware of the root causes of their behavior, most can describe in what capacity the self-injury addresses an immediate need. For “Electra,” a recovered self-harmer, the action of cutting offered a feeling of release. “Like a bomb pent up inside, the pain is so tremendous that tears and screaming, nothing can take it away.” Cutting seemed the only alternative. “Scientifically, it is actually releasing endorphins, the feel-good stuff in our bodies. It gives us a sense of feeling good,” she continues.
But the perceived relief was nothing more than illusion. The practice of cutting became an end unto itself. Electra soon realized that once she started cutting, she couldn’t stop. “I had to really find my triggers, then substitute [the cutting] with another action,” she explains. “I used either ice in my hand, red pens, running in the frigid cold and simply leaving the toxic environment in which I was living.”
“Hannah,” another self-harmer, says she started because of “family trouble, friends trouble, school trouble, depression, anorexia, and feeling like she doesn’t belong or doesn’t deserve life.”
“Sheila” is the marketing director at a “semi-successful company.” She started self-harming at age seven by scratching her face when she felt too much pressure. Her SI behavior escalated to cutting, which she did with the intent of popping an artery. “I still feel that way, but have not done any of this in years,” she says. Like so many self-harmers, Sheila has never seen a doctor for her behavior, but guesses it was stress-related. “After doing it I felt much better and I could go about my day.” She eventually went to a behavioral retreat for drug use, which led to her ceasing to cut.
“Beth” has a daughter, “Eva,” who will be three years old in October. Eva started pulling her hair out about six months ago. Her doctor suggested the behavior might be stress-related, so Beth took her daughter to see a child psychologist. As of this writing, the family has not gained much insight into the problem. The family has noted two situations in which the behavior occurs. The first is when Eva is having a tantrum or not getting her way. The second time appears as a soothing method when she is watching television or going to bed. She tends to twirl it in on her finger and pull it. “She did try to put [the hair] in her mouth a few times, but it seems that behavior has left, which is great,” Beth says. “Well, at least I have not observed it anymore. She sleeps in her own room at night so I don’t know exactly what she could do while sleeping or going to sleep.” Beth adds that Eva hates going to see her pediatrician and pulled her hair while she was in the office and upset. “That is how I initially saw she was doing this type of behavior,” Beth comments. “We had taken her to the doctor months ago when we had noticed her hair was thinning out some in the beginning. Apparently she was doing it at night and now it has spread to more during the day and such.” The psychologist said the family will need to figure out if the behavior is occurring because Eva is tired, but Beth doubts this is the cause, as the behavior persists even after her daughter has slept all night. The family is awaiting a final report from the child psychologist, who suggested Eva see a behavioral specialist once a week to offer tips/suggestions. “She thinks this will be only short-term, as we should be able to get a grip of the behavior soon, I hope. That is about all I know at this point.”
Andrea Bazemore, Editor-in-Chief at Positive Energy Group (www.positivenrggroup.com), is not a self-harmer, but she started counseling people her senior year of high school. It was then that she counseled a girl who usually wore long sleeves or multiple bracelets to cover her cutting scars. “She wasn’t happy with her life. She had a reading disability and was labeled ‘special ed,’” Bazemore describes. “Also, she was having family issues. Her cutting let her have a kind of ‘release’ from all of her problems.”
The girl experienced pressures from school, compounded by parents who were “almost non-existent.” Perpetual drama with the boys at school didn’t help matters. “She had so much built up stress going on in her life that she didn’t talk about to her peers—mainly because her peers were also going through their own struggles. So, she turned to the one outlet that would help her relieve her stress. She resorted to cutting.”
Everyone experiences stress, and teenagers get a particularly heavy dose of new experiences with which they have not previously had to deal. Whereas most people will exercise, talk to their friends, journal, or find something to relieve whatever stress they have, cutters relieve their stress by seeing their blood. “It provides them a visual representation of their pain,” Bazemore says. “They can see it, they can feel it, and for that moment it feels great.
“It seems simple to say that cutting isn’t the correct way of handling stress,” she continues, “but in the mind of a cutter, this reality is hard to accept, because this is the first time they have found a way to cope with their stress that works. It isn’t until they are exposed to healthier methods of coping with their stress do they stop cutting themselves.”
Russell Friedman is Executive Director of The Grief Recovery Institute (www.griefrecoverymethod.com), and an author and regular blogger on Psychology Today’s website (www.psychologytoday.com/blog). He wrote an article on SI for KOTA Press explaining the connection between unresolved grief and self-mutilation. “Grief produces energy,” the article begins. “Unresolved grief produces and sustains even more. People go to great lengths to disperse the energy that mounts inside their bodies. Most of the actions they take are indirect and do not accomplish the goal of completing the grief that caused it. So it generates even more energy. “[SI] is one of those indirect actions people take in an attempt to deal with the build-up of unresolved emotions. The human body is neither designed nor constructed to contain that kind of energy. When there is a massive build-up of emotional energy the body seeks ways to relieve the pressure that mounts inside.”
Friedman uses the term S.T.E.R.B.S (Short-Term Energy Relieving Behaviors) to explain the things people do in an attempt to deal with emotional energy created by a single loss or an accumulation of losses over time. “They are the actions people take as they try to dispel some of the energy that builds up inside of them when they are affected by sad or painful events,” Friedman writes. “In the short term they seem to push aside or even dispel some of that pent-up energy. But at best those actions only create an illusion of well-being. Because the cause of the energy build-up has not been dealt with, the energy will come back.”
SI represents one way in which people try to deal incorrectly with the emotional energy caused by sad or painful events. It can become habit-forming. Friedman explains that, as with other STERBs, SI doesn’t necessarily become pathological, “but it can easily be memorized as a habit that will rear its ugly head again in response to an emotional crisis. As the recovering alcoholic must be ever-alert to the possibility of relapse, so must the reformed cutter be ever-vigilant to the build-up of emotional energy that can lead to a repeat of that behavior.”
Friedman contends that, by effectively completing relationships with all the major people who have affected their lives, self-harmers will remove much of the stimulus that leads to the build-up of energy that requires the use of STERBs.
SI as a Symptom
Self-injury must be seen as a symptom rather than as a disorder or disease, according to David M. Reiss, M.D., a psychiatrist with a private practice in San Diego. Reiss describes multiple different conditions and situations, both psychiatric and neuropsychiatric, that can lead to SI behavior.
“No one diagnosis or ‘explanation’ fits all cases,” Reiss asserts, adding that “causes can include the following:
• neurological disorders
• psychotic illness
• toxic response to psychoactive agents (licit or illicit)
• dissociative illness (a sense of severe emotional disconnection that is ‘relieved’ by the sensation of pain)
• severe depression or (probably most frequently) problems in development of emotional regulation, including unconscious confusion between being loved/cared for and feelings of physical or emotional pain (often related to a history of traumatization).”
Reiss also explains that generalizing as to the cause or the treatment of SI just from the specific symptom of self-injury can often be problematic, leading to misdiagnosis and ineffective treatment. “Any person who participates in self-injury—even if intermittently or to a ‘minor’ extent—merits a full, comprehensive medical and psychological/psychiatric evaluation,” he advises.
Level and Longevity of SI
Over the years, Vann has tallied approximately 30 reasons why people injure. “Each time someone injures, it could be for a different reason—or trigger,” she says. Vann adds that, while not consistent or absolute, she has seen a tendency for the emotion to influence the level of self-harm. “For example, if someone is really depressed, then their cut might be longer or deeper versus someone who is agitated, anxious, or angry, whose cuts might be more superficial in depth, but will have more in number.”
Longevity of SI behavior is another important issue Vann addresses. In other words, if a person who self- harms grows out of whatever situation is causing him/her stress, sadness, or feelings of helplessness, has the SI behavior already developed into an addiction that is continued uncontrollably, and without the same triggers initially associated with the self-injury?
Vann explains that the longevity of SI behavior is multi-faceted. Some people self-harm for a short period of time and grow out of it. “They never got into injury in the first place,” she explains. “It was either experimental or it just never took.” She adds, however, that the longer someone has injured or conversely the more frequently they have injured can indicate the level of resistance to overcome it. “If someone has self-harmed for over a year, but only three times, the behavior is not really ingrained. On the other hand, if a person began self-harming three months ago but the behavior has escalated from once a week to daily, they’re going to be more resistant to stopping,” Vann says.
For adults, oftentimes the persistence of SI is tied to old issues that have never been resolved, including low self-esteem, boundary issues, and a history of abuse. “They may have moved on with their lives, but until they deal with triggers or core issues, they will continue to self-injure or will move on to another addiction,” Vann surmises.
Many of these adults (like Alex, who was introduced at the start of this article) are certain they are beyond help. Vann suggests these individuals suffer from overwhelming shame. “They are guilt ridden and embarrassed, and this plays into the underlying issues that started their SI behavior so many years ago,” she says. “Perhaps it was an emotionally abusive environment where the person had been repeatedly told, ‘You’re bad,’ or ‘Suck it up.’ These messages continue into adulthood. Anytime they do or feel anything construed as odd or abnormal, they’re going to play those tapes over and over again.”
Progression of SI
Jennifer Otero, MA, is Director of Counseling at Mercy Ministries of America. She says that many of the young women who come to the program struggling with self-harm either “stumbled” across this form of “coping” on their own or found out about it from their peer group. “By ‘stumbling’ across it, I mean that they perhaps got angry one night and punched themselves, dug their fingers into their arms or punched a wall and recognized the release that it brought for them emotionally,” Otero explains.
Otero has seen many instances of self-harm that start out small—scratching or burning with erasers—and progress to more extreme forms, such as physically cutting oneself or even burning. “What we have found is that a young woman often progresses in the forms that she uses as her previous forms of self-harm no longer provide the same release,” Otero says. “Sometimes they experiment with higher degrees of self-harm and experience a higher level of release or even euphoria with the release of endorphins that is experienced when harm is initiated.” Otero adds that this euphoria is often what causes self-harmers to return over and over to their SI behavior.
Another reason many young women have reported using self-harm is that it allows them to connect with themselves. “They shared being so numb and depressed that seeing their own blood helped them to recognize that they were still alive.” Otero says. “We have found that some young women do find out about self-harm in the media or on the Internet, but usually it is something that they find out about from their peer groups.”
Perhaps these influences explain why the SI method of coping is trending younger—down to elementary school-aged children, according to Vann. Although she concedes that, as public awareness increases, we are catching SI behavior at earlier ages, she also sees the media and the Internet playing a role in this trend. Society plays another role. “We have such a desire to make elementary kids grow up faster than they should, and that’s a contributing factor,” Vann says. “Kids see teens doing this stuff, and the kids want to be more like teenagers.” She adds that today’s elementary school kids are more stressed, and their parents are more stressed, which trickles down to the kids too.
On the positive side, Vann raises the point that people are actually asking about SI these days, where they weren’t in the past. “It’s like the old wives tale that you shouldn’t ask about suicide, because it puts the idea in someone’s head. The same with self-injury. There’s a way to ask people about it and get an honest response. But it should be someone who understands what SI is, the nuances and the shame factor. You can’t just ask yes or no questions, or you’re going to get an automatic ‘no.’”
Sense of Belonging
JC Shakespeare, LPC, is a clinician in private practice and a high school counselor in Austin. From his experience, the large majority of self-injurers prefer cutting, as it is easily hidden and, unless severe, can be self-treated. “Many teens are drawn to the ritual of cutting, and will have special ‘kits’ that become a sort of totem for the ritual,” Shakespeare says. “The hidden scars then become a sort of secret code—many clients have told me that they can easily spot another cutter, even if the typical person would be unable to identify someone as such. There is a sense of initiation into a special society, one that understands the deep pain associated with living in a confusing world.”
Shakespeare says he has also noticed that cutters who develop greater self-confidence are more likely to allow their scars to become visible. “It is somewhat like the ritual of coming out for gay teens,” he adds.
A Place in Time
Shakespeare believes that the majority of cutting begins as young people enter and encounter the confusing stage of adolescence. He explains that this stage is difficult enough under the best of conditions, so if there are issues that are causing stress, many young teens find themselves overwhelmed by powerful emotions that they feel incapable of bearing. Lack of communication skills, emotional self-regulation, and the inability to self-advocate can all be risk factors for self-injury.
And the result, Shakespeare says, all boils down to this: “Since emotional terror is typically a combination of regret (depression) about the past and anxiety regarding the future, the painful act of [self-injury] allows one’s consciousness to be completely absorbed in the present moment.”
No More Judging
SI is complicated, deeply rooted, and absolutely problematic, both in the near- and the longterm. With so many options for possible causes, the most important thing to take away is that this is not a “B.S. disease” (as it’s often referred to), created by people wanting attention. Most self-injury occurs in private, and scars are hidden from public view, negating this very idea. Even if this were the case, the person who is willing to go to such lengths for attention is in need of help. Help begins by uncovering the secret and talking to someone. There is no shame in the problem or in the emotions that trigger them. There are healthy ways to express these emotions, no matter how dark they may be. And there are many, many people and organizations who can help the self-harmer find the alternative release that works best for him or her. The first resource may be closer than most people think: the ear of a trusted friend or family member. Sometimes the very act of talking about the self-injury sets the self-harmer on the road to recovery. And, although that road may be sometimes dark and bumpy, it will lead to a brighter day than staying on the secret, lonely, unending path of self-injury.
• “Cut: Mercy for Self-Harm” and “Beyond Cut.” Both books are about how to recognize the signs and symptoms of self-harm, understanding how and why these behaviors develop, and how to break free and stay free from self-harm. They include many stories of young girls who once had no hope but now live with joy and freedom. There’s also a special section for parents and others who care about someone who is self-harming. http://mercyministriesbooks.com/
• “The Merciful Scar.” This is a book about self-injury written by experts on the topic.
• sioutreach.org – Resources for those who self-injure to help in efforts to recover, as well as best practice information and resources for the professional working with SI patients. The site offers a general information guide about SI at sioutreach.org/learn/general.
• griefrecoverymethod.com – Grief Recovery Institute website where you can learn more about SI, as well as other S.T.E.R.B.S., and view details about books written by the Institute’s Executive Director, Russell Friedman.
• www.timberlineknolls.com – offers plenty of information on SI, as well as treatment options at its facility.
To Write Love on Her Arms is a non-profit movement dedicated to presenting hope and finding help for people struggling with depression, addiction, self-injury, and suicide. TWLOHA exists to encourage, inform, inspire, and also to invest directly into treatment and recovery. (twloha.org)
• Vans Warped Tour: August 4, 2013, Reliant Center Parking Lot, 2 Reliant Park Houston, TX 77054. Look for the TWLOHA tent in the Take Action area. Info and merchandise available.
• GENaustin’s 6th Annual We Are Girls conference, November 9, 2013, Austin High School, Austin, TX. Each year, there are Houston-area school groups as well as Houston-area moms and daughters that drive 165 miles to Austin for this conference. Parents and those who care about girls (such as school counselors or Girl Scout Leaders) attend to have fun while helping girls learn to cope with issues, and also building and maintaining a girl’s self esteem. www.WeAreGirls.org
SI AWARENESS RIBBONS AND BRACELETS
• Healing the Scars Orange Ribbon Project: nonprofit offers free ribbons and bracelets for SI (if you self-injure); SIR (if you are recovering); and SIA (if you’d like to support those with SI). http://healingthescars.webs.com/orangeribbonproject.htm