The selection of a method - self-injury or suicide?

Just as there are many causes of psychological pain, there are many ways to self-injure. Perhaps the most common method is self-cutting, most often on the arm.

Another method is taking an overdose, i.e., taking drugs until you get sick or even lose consciousness, such as drinking until you pass out.

Note: the kind of harm done in self-injury attempts is usually different from suicide attempts.

Firing a large bullet into your brain or jumping from the 10th floor is definitely suicidal. Cutting your arm or foot isn't a common method for suicide but it's a common method to relieve the emotional hurt one's experiencing or to let others know they're very unhappy.

Some methods may serve either purpose, e.g., taking an overdose of drugs is a common method for both self-injury & suicide. Besides cutting & overdosing, self-injury includes:

• burning yourself
• hitting a wall
• jumping from somewhat high places
• hitting yourself
• self-choking 
• getting others to hurt you

Most self-injury victims clearly differentiate in their minds between self-injury & making a suicide attempt (most self-harmers have had thoughts of suicide in the past but at any one time the intent is usually clear).

People wanting to self-injure may, of course, miscalculate the risks (& they're well aware of possible errors) but they often think of self-injury as a way of relieving their extreme emotional distress & thus, reduce the chance of dying right now.

I don’t want to imply that the distraught self-harmer always has a clear intent in mind - to die or not to die. There are people who injure themselves seriously & are willing to leave the outcome up to chance or fate or to whatever powers they believe in.

To those of us who've never experienced the absorbed obsession associated with intentionally injuring our bodies & have never gotten emotional relief in that way, the whole idea may seem incomprehensible & frankly, rather grotesque.

One’s first thought may be that this is a thinly veiled suicide attempt; i.e., they're really trying to kill themselves but won’t admit it. But as we understand the situation better, we realize that for many self-abusers the act is self-protective, not self-destructive. They don’t want to die.

They want to deal with their troubles & unhappiness; they'd like to find more constructive & effective ways of escaping psychological pain instead of self-injury. But until they discover better ways of coping, when they feel painfully distraught, the urge to self-injure returns.

My Self-Help Forum friends helped me understand that situation. I appreciated that.

Like so much human behavior, self-harm is, at first, hard to understand. Each victim of self-harm is unique, has a different history, a different set of personal problems & a different means of hurting him/herself. There's sometimes a well remembered & understandable original experience with self-injury followed by a long history of using similar self-injury techniques over & over.

A therapist may believe (I think wisely) that the therapeutic task is more to develop some effective methods for dealing with the currently overwhelming emotional troubles rather than to analyze at length the childhood dynamics & reasons for starting to self-injure. But both routes might work.

How rare is self-injury?

There are few studies of the frequency & nature of self-injury. One study (BMJ, Nov., 2002, Volume 325, pp 1207-1211) of 6000 British 15 & 16-year-olds reported that 7% had deliberately hurt themselves sometime in the past (only 1 in 8 of that 7% had hurt themselves seriously enough to go to a hospital).

Another large study of teenagers reported that more than 10% had cut themselves sometime in the past. Hurting yourself may start at any period of life (as early as 6 or 8) but most commonly it starts in the turmoil years of 11 to 14.

Wendy Lader, author of Bodily Harm, estimates that 1% of Americans use self-injury to deal with emotional distress but she says the rate is much higher among teens, especially females. Why more females?

Supposedly, according to Lader, partly because females tend to react inward when upset rather than outward - they'd rather hurt themselves than someone else & besides, openly going into a rage isn’t a very feminine thing to do.

Among people who have this tendency, how often do they self-injure?

A few people may hurt themselves every day, e.g., pull out hair or pick at a sore, but more typically, say with cutting, it may be every few days. Quite often there are several injuries close together & then a break for perhaps weeks or months. Such an irregular schedule makes it hard to know if you've finally stopped hurting yourself or not.

Other causal factors involved in self-injury

Personal characteristics & environmental circumstances sometimes set the stage for self-injury; i.e., people who observe or hear about self-injury very often think of the self-abuser as mentally disordered.

This social perception could well contribute to the self-injurer having low self-esteem. And low self-esteem increases the risk of self-injury.

The 2002 BMJ study mentioned above found that young females hurt themselves 4 times as often as males.

For young women, the risk is increased if they've had family members or friends who self-harmed, been very depressed or anxious themselves, had low self-esteem, had abused drugs, or were impulsive.

For young males, high risk situations included having suicidal friends & relatives, using drugs & having low self-esteem.

We have seen that self-injury usually starts while a person is extremely upset; then in a fit of anger or self-hatred or depression or a feeling that everything's going wrong, the person hits the wall or cuts him/herself or puts a cigarette out on her/his arm… & finds the intense emotional stress is relieved.

This experience - actually the emotional benefits of self-injury - is remembered & may be used again whenever the stress becomes intense again.

Often, just the open, intense expression of feelings cleared the air & resulted in lessening of the stress.

In some cases, the person clearly felt guilty -  felt they'd been bad - & the self-injury took the form of self-punishment. For others, it wasn’t self-punishment at all, but it just felt good to escape the hurtful feelings or to discharge their intense feelings.

After emoting, some felt they were finally communicating & being heard; however, it would be a mistake to dismiss the expressions of genuine feelings during self-injury as being merely attention getting behavior.

Indeed, most self-injury is done in secret & kept secret. Yet, it can be a cry for help. And why not? Most self-abusers feel that no one understands them & no one cares.

The reactions of others to self-injury

Some people become concerned that a person who is so angry that they self-injure is dangerous to others. It's true that some self-injurers are angry with others, but they seem to usually cope with aggression by turning it on themselves.

Professionals don't ordinarily consider self-injurers to be a risk to others. Of course, if the self-injury behavior begins to include aggressive acts, such as bullying or physical threats, then one would rightly have concerns about the welfare of others too.

Naturally, friends or relatives are often upset by this behavior & bluntly urge the self-abuser to stop. Some people who self-injure feel some resentment of this & think “if my hurting myself doesn’t bother me, why should other people be concerned? What’s it to them?”

The answer is that watching or even hearing about self-abusive behavior is troubling to most people, especially if it could be permanent or lethal, if the aggression might extend to others & if the observers don't realize that self-injury can be a method to allay the overwhelming stress.

Most self-abusers, however, in the course of time, feel that they'd like to avoid using self-injury as a coping mechanism. If they can find other ways of soothing their emotional turmoil, the self-injury response will extinguish.

Other people - friends, partners & relatives - often at least have negative feelings about self-injury; it doesn’t immediately arouse sympathy. Instead, it often causes a conflict situation where the self-abuser is criticized & called weird or crazy.

Even experienced therapists may not have dealt with much self-injury before, so like others, they may be baffled by it. Besides, young people often don't take kindly to the comment that “you need to see a shrink” which is said more like an order or a demand, rather than gentle concerned encouragement.

How should one respond to a person who self-injurers?

The simple answer is: with concern & respect, with a desire to understand & help, with no criticism, blame or negative comment. Some self-abusers appreciate getting to talk about their troubles, their feelings & even their self-injuries. Others feel they've been misunderstood, mishandled & neglected before, so “let’s not talk about it.”

Sometimes they get tired of telling the same history over & over without getting help; sometimes they've been told that therapy will not be provided if they continue to self-injure (doesn’t seem empathic, does it?); sometimes their helpers just seem uninterested, treat them like a child, or appear to have little time.

If these are the kinds of experiences self-harmers have had in the past, naturally if you're a newly assigned helper, they aren't going to warm up to you right away. It takes a little time & a lot of genuine concern. They do want help.

In most cases, however, self-injurers feel they were or would be helped by support groups made up of other self-harmers. They don’t believe that more statistical or diagnostic information about self-harm (in the form of the typical brochure in the doctor’s office) would help them very much but they're interested in ways of coping.

Self-injurers often find that the agency service personnel & staff need more information about self-injury.

If you're a parent or a spouse of a self-abuser who also seems to be over-emotional, impulsive, unreasonable, provocative &/or uncontrollable & is driving you crazy, she or he may have a Borderline personality.

If so, get the book, “Stop Walking on Eggshells” by Mason, Kreger, & Siever (1998). It may help you understand your loved one & be less upset by his/her roller coaster behavior. You need to take care of yourself & not get sucked into the loved one’s turmoil.

How do people stop hurting themselves?

I must emphasize again that self-injury is both psychologically difficult to understand & dangerous to one’s health. Therefore, an important & wise first move is to get professional help. I'll mention self-help techniques but please seek therapy with an experienced, well trained practitioner.

WARNING: the following self-help methods, while intended to be helpful, may be described in some details that could trigger a self-injuring response. If you're in a mood to self-harm or if you're responsive to triggers, please don't read this section. If you're unsure of your self-control, please discuss how to reduce self-injury with your therapist soon.

The 2002 British study says the general answer about how people stop self-harming behavior is they start feeling better about themselves. How do they achieve that?

They get their life in order…somewhat. If they're completely “down,” they find a place to live, a way to get food, a place to take care of their kids - real basic stuff (the threat of losing their children is a major stress…& motivator).

They work thru some of their intense feelings from the past & become more able to communicate with others, both to express things they don’t like & to relate more positively. Generally, among the very poor & disadvantaged in Britain, finding a supportive environment (living conditions & helpful friends) was a crucial step towards achieving an acceptable adjustment.

In their personal lives, some of the subjects in the British study who had reduced or quit self-harming had made use of self-help methods, e.g., a few had switched from hurting themselves to a somewhat controlled smashing of things, like breaking glassware or hitting objects with a bat.

Others had substituted using alcohol or drugs to relax or distract themselves instead of self-injury.

Another approach is to cause pain in some less objectionable way, such as flipping your wrist with a strong rubber band or holding your hand in ice water or maybe just holding an ice cube.

A few people can substitute an imagined injury for an actual injury, e.g., by just thinking about cutting yourself or maybe marking with a red marker the place on your arm where you might cut & where the blood would flow, if you did it.

Instead of bodily hurting themselves, some people can vent their anger with physical exercise, e.g., do some real hard work, mow the lawn, lift heavy furniture, squeeze a pillow hard, workout at a gym & in some of these ways feel less need to feel pain.

Breaking the chain of events early is possible (see chapter 11). Some had learned to detect early a troublesome downward train of thought leading to self-injury & then they learned to consciously focus on distracting thoughts, such as watching TV, listening to music, taking a nap, or reading a magazine or book.

Still others found the chain of thought leading to more serious depression or self-hatred could be broken early by talking to supportive people, calling their therapist (or just thinking about topics for the next session), or posting to an online self-injury group (or imagining the conversation at the next support group meeting).

Also, a few found interesting activities to do, like relaxing & meditating (see chapter 12), going shopping or for a walk or a workout, writing their life story (see chapter 15), or doing drawings or art work to express their feelings.

More self-help ideas

Make a serious, effort (it'll take therapy or weeks on your own) to understand these awful feelings that start & generate this whole process.

Ask:

• “Why am I feeling so awful?”
• “Are my thoughts & feelings reasonable? If not, what unreasonable beliefs do I have that give me such a heavy emotional load & sap my self-esteem?”
• “How can I change these feelings & get a more realistic view?”

During some good times, prepare a list of things in your life that you appreciate, really enjoy, value & feel grateful for. Use this list (keep it updated) as a handy reminder when depressed that there are good things in your life as well as bad things.

Be sure to include your good traits, talents, good deeds, assets, beautiful parts, etc., showing you aren’t as bad as you sometimes think you are.

Procrastinate doing self-injury. Tell yourself to put self-criticism or self-injury off until later - “maybe tomorrow.” Most impulses lose their urgency when you put them off…especially if coupled with keeping your mind on other things. The need to feel pain will diminish also because the deep depression, self-hatred, guilt or whatever has declined.

The environment is a powerful determinant of our behavior (see chapters 4 & 11). Hide away stuff you use to self-injure. Stay out of the room, chair, sink, or situation you usually hurt yourself in. Don’t go there mentally or physically. If you are “triggered” somewhere (a room, a TV show, a book, a discussion, an idea), quickly get out of that situation & think about other things.

Develop a routine to easily use when feeling especially bad - nurture, even “baby” yourself. Perhaps go for ice cream with a friend, take a long, warm bath, look at especially selected pictures of good times & people you love, play with a pet, develop special activities with your family, enjoy a nice romantic/erotic story, etc.

Sometimes people find it helpful to sign an agreement with someone to not self-harm without calling them first. For very distraught times, however, the contract may not be a strong deterrent.

The above methods have worked for at least a few people. No one method works for all people who self-injure. The methods that work are usually tailored for a specific person. I hope this long list helps you believe that you too can devise several techniques that might guide you away from deep depression &/or self-injury. Then try them out.

Changes needed in psychological services: Look beyond the scars

The British study group that I have cited several times found major deficiencies in professional care for the people who self-injure. I believe the situation in the US is similar.

First, our institutions provide the same services for suicide & for self-injury, namely, medication & hospitalization or out-patient treatment. But people who self-harm see traditional psychiatric hospital treatment as poorly understanding their needs (often negative & dismissive) & thus, unlikely to give good service.

Needed are specific facilities & trained staff that would provide understanding, respectful, caring “safe houses” for a day or a few days; counselors specializing in self-injury; education & counseling for children, spouses, parents or friends involved; self-help instruction & self-help support groups; special attention to child care while families are broken up; & so on.

Some available literature

The major search engines will fetch many Web sites providing information & concrete suggestions for coping with self-injury. Note particularly PsychCentral & Healthyplace.com.

Other Web sites provide support groups, understanding articles & suggestions for dealing with self-injury: Self-Injury: You are NOT the Only One & Self-help methods with self-injury are described in Stopping Self-Injury & in this article Self-Inflicted Violence: Helping those who Hurt Themselves by Tracy Alderman.

Two large Web sites cite many articles & review over 75 in print books in this area: Home-Health-Conditions-Self-Injury & Self-Injury Books.

There are a surprising number of books in print about this general topic, a couple by Clinical Psychologists & therapists:

• Alderman (1997) & Levenkron (1999)
• one by therapists who recommend extensive inpatient treatment (Conterio, Lader & Bloom, 1999)
• another by a psychiatrist (Favazza, 1996) 
• two by journalists who interviewed people with this compulsion (Hyman, 1999) & (Strong, 1999).

Any of the books can help you become aware & empathize with a self-harmer but I’d suggest one of the books written by a professional.