Note by Devin Hastings: Ron Stubbs is an amazing person whose skills are only exceeded by the care that he has for those who are in pain. The below article by Ron is well-worth reading.
Self-Inflicted Violence (SIV)
By Ron Stubbs, C.Ht.
AUTHORíS NOTE: Approximately 1 out of every 10 people, 10% of the population has, at one time or another, used self-inflicted physical injury as a means of coping with an overwhelming situation or feeling.
SIV has neither cultural boundaries nor limits on social classes. People from every walk of life, from Princess Diana, and soccer moms to the adolescent neighbor next door, rich and poor alike have silently suffered from this behavior.
Self-harm scares people. The behavior can be disturbing and difficult to understand, and it is often treated in a simplistic or sensational manner by the press. As a result, friends and loved ones of people who self-injure often feel frightened, isolated, and helpless. Sometimes they resort to demands or ultimatums as a way of trying to regain some control over the situation, only to see things deteriorate further.
The first step toward coping with self inflicted violence (SIV) behavior is education: bringing reliable information about who self-injures, why they do it, and how they can learn to stop to people who self-injure and to their friends, loved ones, and medical caregivers.
This article contains potentially distressing material. If you self-injure now or have in the past, please make yourself safe before reading this article. For many people who self-injure, there comes a breakthrough moment when they realize that change is possible, that they can escape, that things can be different. They begin to believe that other tools do exist and begin figuring out which of these non-self-destructive ways of coping work for them. It is my sincere hope to help them come closer to that moment.
Understanding is the first step.
In This Article:
We all do things that aren't good for us and that sometimes may harm us. We also do things that inflict injury but that are primarily intended for other purposes. Some self-inflicted harm is culturally sanctioned, while other types are seen as pathological. Where does one draw lines?
An easy line to draw is that of deliberate, immediate physical harm being done. For example, cutting your arm or hitting yourself with a hammer are clearly self-injurious acts. Behavior like overeating, smoking, not exercising, etc., are harmful to a person in the long run but are not motivated by a desire for immediate physical damage. What, then, about acts like tattooing and piercing, where physical modification of the body is deliberate and desired?
The first step in classifying self-injury is to sort out what makes a type of self-injury pathological, as opposed to culturally sanctioned. Socially sanctioned self-injury can be categorized into two groups: rituals and practices. Body modification (piercing, tattoos, etc) can fall into either class.
Rituals are distinguished from practices in that they reflect community tradition, usually have deep underlying symbolism, and represent a way for an individual to connect to the community. Rituals are done for purposes of healing (mostly in primitive cultures), expressions of spirituality and spiritual enlightenment, and to mark place in the social order. Practices, on the other hand, have little underlying meaning to the practitioners and are sometimes fads. Practices are done for purposes of ornamentation, showing identification with a particular cultural group, and in some cases, for perceived medical/hygienic reasons.
Non-socially sanctioned (pathological) self-injury can be classified as either suicidal, self-mutilation (which is further broken down into major, stereotypic, and superficial/moderate), or unhealthful behavior. According to the American Journal of Psychiatry, the three components of SIV acts are: directness, lethality, and repetition.
Directness: refers to how intentional the behavior is; if an act is completed in a brief period of time and done with full awareness of its harmful effects and there was conscious intent to produce those effects, it is considered direct. Otherwise, it is an indirect method of harm.
Lethality: refers to the likelihood of death resulting from the act in the immediate or near future. A lethal act is one that is highly likely to result in death, and death is usually the intent of the person doing it.
Repetition: simply refers to whether or not the act is done only once or is repeated frequently over a period of time.
Perhaps the best definition of self-injury is found in the American Journal of Psychiatry (Winchel and Stanley (1991), which defines it as: The commission of deliberate harm to one's own body. The injury is done to oneself, without the aid of another person, and the injury is severe enough for tissue damage (such as scarring) to result. Acts that are committed with conscious suicidal intent or are associated with sexual arousal are excluded.
Mosby's Medical, Nursing, and Allied Health Dictionary (1994) contains the following definition: Self-mutilation, high risk for a nursing diagnosis . . . defined as a state in which an individual is at high risk to injure but not kill himself or herself, and that produces tissue damage and tension relief. Risk factors include being a member of an at-risk group, inability to cope with increased psychological/physiological tension in a healthy manner, feelings of depression, rejection, self-hatred, separation anxiety, guilt, and depersonalization, command hallucinations, need for sensory stimuli, parental emotional deprivation, and a dysfunctional family. Groups at risk include clients with borderlines personality disorder (especially females 16 to 25years of age), clients in a psychotic state (frequently males in young adulthood), emotionally disturbed and/or battered children, mentally retarded and autistic children, clients with a history of self-injury, and clients with a history of physical, emotional, or sexual abuse.
Malon & Berardi, in an article called "Hypnosis with self-cutters" from the American Journal of Psychotherapy (1987), summarize the process they believe underlies self-injury: Investigators have discovered a common pattern in the cutting behavior. The stimulus...appears to be a threat of separation, rejection, or disappointment. A feeling of overwhelming tension and isolation deriving from fear of abandonment, self-hatred, and apprehension about being unable to control one's own aggression seems to take hold. The anxiety increases and culminates in a sense of unreality and emptiness that produces an emotional numbness or depersonalization. The cutting is a primitive means for combating the frightening depersonalization.
Stereotypic self-mutilation tends also to be direct, repetitive, and of low lethality, whereas major self-mutilation is direct, not repetitive, and of low lethality. Moderate self-injury can be further divided into impulsive and compulsive.
Self-injury can be separated into three types. Major self-mutilation (including such acts as castration, amputation of limbs, enucleation of eyes, etc) is fairly rare and usually associated with psychotic states. Stereotypic self-injury comprises the sort of rhythmic head-banging, etc, seen in autistic, mentally retarded, and psychotic people. The most common form of self-mutilation is called superficial or moderate. This can include cutting, burning, scratching, skin-picking, hair-pulling, bone-breaking, hitting, deliberate overuse injuries, interference with wound healing, and virtually any other method of inflicting damage on oneself. Both in clinical studies and in an informal Usenet survey, the most popular act was cutting, and the most popular sites were wrists, upper arms, and inner thighs. Many people have used more than one method, but even they tend to favor one or two preferred methods and sites of abuse.
We can further break down superficial/moderate self-injury into three types: compulsive, episodic, and repetitive. Compulsive self-injury differs in character from the other two types and is more closely associated with obsessive-compulsive disorder (OCD). Compulsive self-injury comprises hair pulling (trichotillomania), skin picking, and excoriation when it is done to remove perceived faults or blemishes in the skin. These acts may be part of an OCD ritual involving obsessional thoughts; the person tries to relieve tension and prevent some bad thing from happening by engaging in these self-harm behaviors. Compulsive self-injury has a somewhat different nature and different roots from the impulsive (episodic and repetitive types).
Both episodic and repetitive self-injury are impulsive acts, and the difference between them seems to be a matter of degree. Episodic self-injury is self-injurious behavior engaged in ever so often by people who don't think about it otherwise and don't see themselves as "self-injurers." It generally is a symptom of some other psychological disorder.
What begins as episodic self-injury can escalate into repetitive self-injury, which many practitioners believe should be classified as an impulse-control disorder. Repetitive self-injury is marked by a shift toward reflecting on self-injury even when not actually doing it and self-identification as a self-injurer. Episodic self-injury becomes repetitive when what was formerly a symptom becomes a disease in itself (as seen in the way many people who self-injure describe self-injury as being "addictive"). It is impulsive in nature, and often becomes a reflex response to any sort of stress, positive or negative. Just like smokers who reach for a cigarette when they're overwhelmed, repetitive self-injurers reach for a lighter or a blade or a belt when things get to be too much.
Should self-injurious acts be considered botched or manipulative suicide attempts?
Although these behaviors are sometimes referred to "Para suicide," most researchers recognize that the self-injurer generally does not intend to die as a result of his/her acts.
Further support for the distinct nature of self-injury comes from a study of psychiatric diagnoses among self-injurers as opposed to attempted suicides. Research has shown that:
14% of self-injurers (SI) were diagnosed with major depression, as opposed to 56% of the suicide-attempters (SA).
Alcohol dependence was diagnosed in 16% of the SI group, but in 26% of the SA group.
2% of the SI group was considered schizophrenic; 9% of the SA group was.
Informal surveys collected via the net reveal that many of those who injure themselves are strongly aware of the fine line they walk, but are also resentful of doctors and mental health professionals who mistake their incidents of self-harm as suicide attempts instead of recognizing them as the desperate attempts to stave off suicide that they often are.
What self-injurers say SIV does for them
Escape: from emptiness, depression, and feelings of unreality. In order to ease tension.
Relief: when intense feelings build, self-injurers are overwhelmed and unable to cope. By causing pain, they reduce the level of emotional and physiological arousal to a bearable one.
Expression of emotional pain
Escaping numbness: many of those who self-injure say they do it in order to feel something, to know that they're still alive.
Obtaining a feeling of euphoria
Continuing abusive patterns: self-injurers tend to have been abused as children. Sometimes self-mutilation is a way of punishing oneself for being "bad."
Relief of anger: many self-injurers have enormous amounts of rage within. Afraid to express it outwardly, they injure themselves as a way of venting these feelings.
Biochemical relief: there is some thought that adults who were repeatedly traumatized as children have a hard time returning to a "normal" baseline level of arousal and are, in some sense, addicted to crisis behavior.
Obtaining or maintaining influence over the behavior of others
Exerting a sense of control over one's body: grounding in reality, as a way of dealing with feelings of depersonalization and dissociation
Maintaining a sense of security or feeling of uniqueness
Expressing or repressing sexuality
Expressing or coping with feeling of alienation
Brain chemistry may play a role in determining who self-injures and who doesn't. One research study published by the American Journal of Psychiatry in 1992 found that people who self-injure tend to be extremely angry, impulsive, anxious, and aggressive, and presented evidence that some of these traits may be linked to deficits in the brain's ceratonin system. It has been suggested that perhaps irritable people with relatively normal ceratonin function express their irritation outwardly, by screaming or throwing things; people with low ceratonin function turn the irritability inward by self-damaging or suicidal acts. It has also been suggested that the degree of self-injury is related to ceratonin dysfunction.
The overall picture seems to be of people who:
strongly dislike/invalidate themselves
are hypersensitive to rejection
are chronically angry, usually at themselves
tend to suppress their anger
have high levels of aggressive feelings, of which they strongly disapprove and often suppress or direct inward
tend to act in accordance with their mood of the moment
tend not to plan for the future
are depressed and suicidal/self-destructive
suffer chronic anxiety
tend toward irritability
do not see themselves as skilled at coping
do not have a flexible repertoire of coping skills
do not think they have much control over how/whether they cope with life
tend to be avoidant
do not see themselves as empowered
Research estimates that 750 per 100,000 population exhibit self-injurious behavior (more recent estimates are that 1000 per 100,000,or 1%, of Americans self-injure). In a 1986 survey, researchers found that 85 to 97% of respondents were female, and they compiled a "portrait" of the typical self-injurer. She is female, in her mid-20s to early 30s, and has been hurting herself since her teens. She tends to be middle- or upper-middle-class, intelligent, well educated, and from a background of physical and/or sexual abuse or from a home with at least one alcoholic parent. Eating disorders were often reported. Types of self-injurious behavior reported were as follows:
Cutting: 72 percent
Burning: 35 percent
Self-hitting: 30 percent
Interference w/wound healing: 22 percent
Hair pulling: 10 percent
Bone breaking: 8 percent
Multiple methods: 78 percent (included in above)
On average, respondents admitted to 50 acts of self-mutilation; two-thirds admitted to having performed an act within the past month. It's worth noting that 57 percent had taken a drug overdose, half of those had overdosed at least four times, and a full third of the complete sample expected to be dead within five years.
In her book "Women Who Hurt Themselves: A Book of Hope and Understanding, author Dusty Miller also notes one explanation for why such a large majority of these patients are female: women are not socialized to express violence externally. When confronted with the vast rage many self-injurers feel, women tend to vent on themselves.
Miller states, "Men act out. Women act out by acting in." Another reason fewer men self-injure may be that men are socialized in a way that makes repressing feelings the norm. Adding to that theory is that self-harm results in part from chronic invalidation, from always being told that your feelings are bad or wrong or inappropriate, and could explain the gender disparity in self-injury; men are generally brought up to hold emotion in.
Borderline Personality Disorder,
Post-Traumatic Stress Disorder
Anxiety and/or Panic
Self-injury as itself a diagnosis
In order to help those who self-injure, therapists must understand what role this powerful coping mechanism plays in their clients' lives. Is it primarily a means of releasing tension? Grounding? Communicating? Reliving painful experiences? Understanding why a particular person self-injures is key to helping that person stop using self-harm as a primary coping mechanism. In their 1996 book, Journal of Adolescence; Young women who self-injure, Yvette Solomon and Julie Farrand state: "Having immediate cessation of self-injurious behavior as a primary goal may well be counter-productive, techniques based on the premise that self-injury should not be reinforced by attention, or on the use of sanctions such as withdrawal of treatment, will almost certainly cause greater distress."
Therapists need to examine their own motives for wanting a client to cease or stabilize his/her self-injurious behavior. Too often, care providers focus on stopping the SI as quickly as possible because they themselves are not comfortable with it -- it repulses them, makes them feel ineffective, frightens them, etc. Situations like this can easily deteriorate into a power struggle in which the therapist insists that the behavior stop and the client chooses to self-injure covertly and becomes uncommunicative and distrustful, thus reducing the chance that a useful therapeutic alliance will be formed. On the other hand, it is legitimate for therapists to help clients devise some sort of plan for dealing with self-injurious impulses and getting their lives (including SIV, i.e. self inflicted violence) stabilized. When a client is engaging in uncontrolled self-injury, the SI and their crises take center stage in therapy, leaving no room for dealing with core issues. In order to have a minimum of stability in treatment, therapists must walk a fine line between attempting to repress/control all self-injurious behavior and allowing the SIV to dominate the therapy.
Since successful treatment of SIV depends heavily on teaching the client new ways of coping with stressors so that underlying painful material can be dealt with, hospitalization should be used only as a last resort when the client is at risk for suicide or severe self-injury. Hospitals are artificially safe environments, and the necessary tasks of learning to identify the feelings behind the act and of choosing a less-destructive method of coping need to be practiced and reinforced in the real world. Additional research shows that the use of high-dose SSRIs and mood stabilizers are beneficial to get the SI under control quickly, then suggests that care be managed under a team concept, compromised of an overseeing MD or psychiatrist who manages meds and coordinates care, a psychotherapist, and the client.
Hypnotic relaxation techniques have been used, with some success, as an adjunct to therapy. D. W. Malon & D. Berardi, "Hypnosis with self-cutters", American Journal of Psychotherapy (1987), states "treating those who self-injure requires that the therapist realize the conflicting needs of the therapist to be in charge of the relationship and of the patient to be treated like an equal; if the patient's need for being seen as an equal isn't met, no progress can be made with or without hypnosis".
The study in question reports success with three types of hypnosis:
Breath counting: the client is led into a trance and instructed to notice his/her breathing, counting each deep slow breath.
Positive imagery: the client is put into a trance state and instructed to visualize himself/herself in a calm, pleasant, relaxing place doing something he/she enjoys. This image is held for a while.
Affect bridge: after trance is achieved, the client is asked to use the current unpleasant feelings to remember other times in his/her life when he/she's felt this way. Memories that are too distressing to talk about in a normal state can sometimes be talked about in a trance state.
It's important to note that in all of these techniques, the therapist must remain neutral to the client, offering encouraging words when appropriate, providing compassion and support but not being drawn into the drama of the SI. Proper training in Affect Bridge, Hypnoanalysis and correct hypnotic regression techniques are vital to the success of the therapy. It is of utmost importance that if the therapist is not comfortable or adequately trained in dealing with SI that the client is referred to a qualified therapist. Malon and Berardi go so far as to say that "simple hypnotic techniques...offered the most immediate relief when delivered with a strong communicative focus and close here-and-now contact."
Show that you see and care about the person in pain behind the self-injury
Show concern for the injuries themselves. Whatever "front" they may put on, a person who has injured himself/herself is usually deeply distressed, ashamed, frightened and vulnerable. It is cruel and counter-productive to "withhold attention". You have an opportunity to offer compassion and respect; to show them something different from the way they have been treated by most people in their lives.
Make it clear that self-injury is okay to talk about, and can be understood.
Convey your respect for the person's efforts to survive, even though this involves hurting herself.
Help her make sense of her self-injury. For example: ask when the self-injury started, and what was happening then. Explore how self-injury has helped the person to survive (physically and emotionally), in the past and now. Ask how she feels before she hurts herself, and how she feels afterwards. Retrace with her the steps leading up to an incident of self-injury - the events, thoughts and feelings that led to it.
Acknowledge how frightening it may be to think of living without self-injury.
Encourage the person to use the urge to self-injure as signals of buried feelings, memories, needs. (These will be unfamiliar and frightening; go slowly and offer support.) Help her learn to express these in other ways, e.g. talking, writing, drawing, or hitting something. Encourage her to ask for support and to care for herself.
Help the person to break down isolation and shame and to build up support networks. (e.g. groups.)
Don't see stopping self-injury as the most important goal. A person may make great progress in many ways and still need self-injury as a coping method for some time. Self-injury may also worsen for a while when previously buried issues or feelings are being explored, or when old patterns and ways of living are being changed. This can be frightening but is understandable.
It takes a long time for a person to be ready to give up self-injury. Encourage her and yourself by acknowledging each small step as a major achievement. Examples of very valuable steps might be: taking fewer risks (e.g. avoiding drinking if she thinks she is likely to self-injure); taking better care of the injuries; putting off hurting herself for a day of an hour; reducing the severity or frequency of the injuries even a little. In all cases more choice is being exercised the "hold" of self-injury is being loosened.
Adolescent Psychiatric Services at Fairfax Hospital 10200 N.E. 132nd Street Kirkland, Washington 98034 Telephone: 425-821-2000 Toll free: 800-435-7221 Fax: 425-821-9010
Behavioral Technology Transfer Group 4556 University Way NE, Ste 222 Seattle, WA 98105 Phone: 206/675-8588
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