UNDERSTANDING AND ADDRESSING SELF-INJURY
Self-injury can include any number of behaviors, including ritual self-harm. These behaviors are not socially sanctioned (e.g. piercing, tattooing). Self-injurious behaviors include cutting, burning, picking, scratching, carving, and insertions of objects under the skin. In addition, it also includes eating, drinking or swallowing non-food items. There can also be other high-risk behaviors such as fighting, sex, or jumping out of a moving car (Juzwin, 2011). There is also a high level of comorbidity among individuals who engage in self-injurious behaviors, eating disordered behaviors, as well as abusing substances. It is critical to understand that self-injury goes beyond the behavior. It also involves thinking, feeling, and reacting. These thoughts are usually very powerful, self-destructive, attempting to always gain control, and to override emotions. These thoughts are often highly distorted and most likely based on feelings rather than facts. Therefore, therapy needs to go beyond behavior management and attend to these distorted thoughts. According to Ross et al. (2008), 13.9% of people in the community, up to 50% of teenagers, and 35% of college students have admitted to injuring themselves. Most individuals who self-injure never tell their therapist about their self-injury. Often times, individuals will self-injury inconspicuously (e.g. hip, inner thigh, under the breast, etc.). It is crucial for therapists to ask specific questions during the intake or therapy session (e.g., “How is the behavior helpful?”, “Where on your body do you prefer to self-injure?”, “What tools do you use to self-injure?”, etc.). We must not shy away from these questions, as we need to encourage a new, healthy way to communicate so that we may move beyond the behaviors and understand the purpose and the thoughts/feelings that continue to perpetuate the cycle of behaviors.
Individuals engage in self-injurious behaviors for many reasons. These behaviors have a purpose and that is to help individuals manage and cope with life’s stressors. According to Nock & Cha (2009), these are some of the most common reasons individuals choose to self-injure:
1.) To feel something, usually from a numb or empty state (self-injury releases endorphins that increase feelings of pleasure).2.) To escape or lessen bad or negative feelings/thoughts3.) To communicate needs 4.) To avoid or escape demands
It is important to note that someone who self-injures may be suicidal or have suicidal thoughts, but not everyone who engages in self-injury is suicidal. It is essential to understand that the purpose of self-injury behavior is in fact to stay alive. Self-injury is a coping strategy, it’s just a very maladaptive coping strategy. Many clinicians use the term Nonsuicidal Self-Injury or NSSI in order to highlight that a person purposely harms oneself without the intent of dying. According to Nock and Kessler (2006), more than half (52.9%) of individuals reported that they engaged in self-destructive behaviors to “stop bad feelings” and not to die. Furthermore, studies have shown that suicidal individuals will often attempt suicide during periods of time when they are not engaging in self-injury to cope with stressors (Gratz, 2006). According to Juzwin (2011), The following key points are recommendations when supporting someone who engages in self-injurious behaviors:
1.) Encourage the individual to seek out professional help or to confide in their therapist. 2.) It is critical to understand what the “purpose” of the behavior is. Ask the individual, “How is it helpful?” versus “Why did you do it?”3.) Encourage the person to develop healthier ways to manage coping in their life. For example, using physical strategies such as progressive muscle relaxation, yoga, meditation.4.) Increase frustration tolerance and practice delayed gratification.5.) Encourage strategies to improve emotion regulation (learning to think through the problem instead of reacting emotionally). 6.) Develop new communication strategies to communicate difficult thoughts and feelings.7.) Encourage the individual to surround oneself with healthy peers who encourage healthy and safe behaviors. Unfortunately, it has been my experience that many clients have learned these behaviors through their peer group. For parents and clinicians, it’s important to encourage the individual to identify red flag behaviors in relationships (e.g. peer pressure, peers engaging in other high risk behaviors).8.) When a child or teenager is involved, several family dynamics need to be addressed in the context of family therapy.9.) Encourage the individual to view themselves as having worth and value.10.) Encourage healthy and safe decision making.11. Do NOT label the person by their behavior, “cutter.” 12.) Understand that the process of change takes time.13.) Set healthy limits and boundaries as a parent and clinician.14.) If an individual is using the behavior to seek attention, we must not punish them for wanting our attention. It is quite ordinary, for example, for a child to want a parent’s attention. However, we must encourage appropriate ways to accomplish this. Parents must be open to giving a child positive attention for positive and age-appropriate behaviors.
References:Gratz, K.L. (2006). Risk factors for deliberate self-harm among female college students: The role and interaction of childhood maltreatment, emotional inexpressivity, and affect intensity/reactivity. American Journal of Orthopsychiatry, 76, 238-250. Juzwin, K.R. (2011). Self-Destructive Behaviors, Self-Injury and Nonsuicidal Self-Injury: A Therapist’s Guide for Family Work & Support. ISBN: 978-1-4490-2241-9.Nock, M.K. & Cha, C.B. (2009). Psychological models of Nonsuicidal self-injury,Understanding Nonsuicidal self-injury: origins, assessment, and treatment. Nock, M.K., (ed). Washington, D.C.: American Psychological Association.Nock, M.K., & Kessler, R.C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures; analysis of the National Comorbidity Survey. Journal of Abnormal Psychology, 115, 616-623.Ross, S., Heath, N. & Toste, J.R. (2008). Non-suicidal self-injury and eating pathology in high school students. American Journal of Orthopsychiatry, 1, 83-92. - Rhiannon Seward, Psy.D., Ext. 406