What Drives Self-Injury and How to Treat It
Understanding is the first step
Child Mind Institute
Self-injury is a disturbing, confusing behavior, and it is unfortunately one to which young people seem vulnerable. People of all backgrounds practice self-injury, but research shows that most self-injurers are girls who come from middle or upper class families and have low self-esteem. Princess Diana admitted that she self-injured while married to Prince Charles and more recently former Disney star Demi Lovato said that she struggled with cutting herself. But while self-injurious behavior has been getting more recognition in the media, it remains a dark secret for the kids who keep their self-injury hidden, and a consuming worry for the families who can't understand why their daughter would want to hurt herself.
Self-injurious behavior isn't considered an official psychiatric disorder, but doctors recognize it as a pattern of behavior that can accompany disorders. The most common form of self-injury is cutting or scratching the skin with anything that can draw blood, such as razors or even paperclips and pen caps, but people also self-injure by burning themselves, picking at skin and wounds, hitting themselves, whatever causes harm. Onset is often around puberty.
Self-injury might look like suicidal behavior, but it actually isn't. People who self-injure aren't trying to kill themselves, they are trying to alleviate whatever emotional distress they are feeling. However, the behavior indicates a depth of psychic pain that could lead to a suicide attempt. The behavior is also inherently dangerous because people who self-injure may hurt themselves more seriously than intended or develop infections or other medical complications.
Understanding the drive
It's hard to understand why anyone would want to injure themselves, or why that injury would come as a relief, as many self-injurers describe it. People give different reasons for doing it. Some people report that self-injury serves as a distraction for them, says Ron Steingard, MD, a psychiatrist at the Child Mind Institute. When they are feeling intense psychological pain, cutting localizes pain somewhere else, mitigating their psychological pain. Other people self-harm because they feel deadened inside. "They've locked down so tightly because of whatever's going on in their lives that they feel they're incapable of feeling anything at all," says Dr. Steingard. "So they hurt themselves in order to feel something."
In some cases self-injury can also become a way of communicating. When people discover that a loved one is intentionally hurting herself, they will most likely have a serious reaction. And if that reaction is one of empathy and concern—especially a degree of concern that the self-injurer hadn't been getting—then it might become a way of nonverbally communicating the next time she's feeling desperate.
But self-injury isn't always a form of communication. Some people are very secretive about the habit, and are focused only on ameliorating their own pain, not sharing it. "It is a complex behavior and there isn't one way to understand it," notes Dr. Steingard. "At points in time self-injurious behavior may have multiple explanations within the same person, serving multiple purposes at once."
Whatever the reason, self-injurious behavior develops as what clinicians call a maladaptive coping tool. This means that people who injure themselves are doing it with the intent to moderate something going on in their lives, and even though self-injury isn't the best way to manage their problems, it does bring temporary relief. Unfortunately that relief makes self-injurious behavior very reinforcing, so kids come to rely upon it as a way to deal with their psychological state. When things are going well they might stop the behavior, but they are still likely to fall back on it in moments of hardship until they find a better way to address their problems. And the longer they practice self-injury the more reinforcing it becomes.
The first step to treating self-injurious behavior is determining what drives a person to want to hurt herself. It doesn't necessarily indicate a psychiatric disorder but it always warrants intervention. A person self-injuring may have very low self-esteem and feel deeply insecure. She may feel lonely and rejected or live in an emotionally impoverished environment. Mood disorders—such as depression and bipolar disorder—and borderline personality disorder are both associated with self-injurious behavior, as is abuse. Getting your child an evaluation with a good mental health professional is important if you learn that she has been hurting herself, even if she says it was a one-time thing. It's true that kids might experiment with self-injury, especially if they have friends who are doing it, but it's a serious and dangerous behavior, and you don't want to ignore what might be a real mental health issue.
As part of her treatment your child's doctor should help her develop a wider set of coping skills to deal with whatever is making her want to harm herself. Dialectical behavior therapy, which teaches techniques for tolerating distress and emphasizes mindfulness, has shown to be particularly helpful to people with self-injurious behavior. Cognitive behavior therapy is also beneficial. Doctors may prescribe medication, in addition to behavioral therapy, to help manage any psychiatric disorders. Other forms of therapy, such as family therapy, may also be appropriate.
Finally, Dr. Steingard recommends that families try to be open and supportive. Ignoring the problem or fighting about it won't help, and it isn't something that you can simply order a child to stop doing. "Most people will never get to the degree of psychological pain where self-injury looks like an alternative, so it's hard to understand," notes Dr. Steingard. "This is a behavior that's very hard for people to get inside and empathize with. But it isn't something that a person can just stop; it's something that needs to be understood."
Published: March 5, 2013