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By Janis Whitlock, MPH, Ph.D., and Elizabeth Lloyd-Richardson, Ph.D.
An estimated one in five secondary school and college-age youth have intentionally cut, burn, carve, bruise, or otherwise injured their bodies without the intention of committing suicide. Indeed, lifetime rates of self-injury in adolescents (estimates range from 13% to 25%) qualify as an epidemic.
But why? Those of us who came of age before bodies became billboards and canvasses for self-expression often have trouble understanding why anyone would deliberately cut their bodies up. If I had a research dollar for every adult over 35 whose jaw has hit the ground and whose eyes grow wide at the mere mention of the behavior, we would be able to answer many of the outstanding questions that remain.
The assumption, of course, is that these are tortured souls endeavoring to end their lives (or practice for that day). In fact, however, self-injury is almost never a suicide attempt and almost always a way of coping, albeit a difficult to understand way of coping. For the significant numbers of otherwise normally functioning teens who self-injure, it serves as a way of dealing with stress. Youth who are very adept at picking up emotional cues from their environment but less adept at dealing with the chain of beliefs and emotions that follow are at higher risk than their more emotionally regulated peers - particularly if they have already experienced unmitigated emotional trauma.
Highly traumatized youth, youth struggling with issues related to past sexual abuse, and youth struggling with other internalizing disorders such as disordered eating, depression or anxiety are also at elevated risk. Although the jury is still out on whether self-injury is primarily a female practice, it is clear that girls are far more likely than boys to disclose their practice. The jury is not out on whether there is a relationship between sexual orientation and self-injury - bisexual youth, particularly women, are much more likely to report self-injury. We see no differences by ethnicity or socio-economic status - though thorough study of these relationships remains rare.
One of the most startling aspects of self-injury is the fact that for many people it seemed to spring up virtually overnight. When we started studying self-injury in 2004 ("we" being the Cornell Research Program on Self-Injurious Behavior: www.crpsib.com), there existed only a very small body of research about it - despite the fact that reports of its prevalence from those who worked directly with youth suggested that it was quite common. In the six years since that time the literature has grown exponentially. Here are a few things I have learned in the course of my study of self-injury:
1.Self-injury often emerges from normal and healthy impulses to feel better, self-integrate, to feel connected to oneself and to others, and to manage overwhelming emotion;
2.Symbolically speaking, the act of self-injury is, for many, is an act of agency - it concentrates the pain into one physical area in which the actor plays all roles: inflictor of pain, endurer of pain, and healer of pain. In this is reflects physically what the injurer wishes to do emotionally - namely to successfully endure and heal pain.
3.Individuals who practice self-injury are often emotionally perceptive but tend to attach negative stories to the emotions they pick up in others and/or struggle with regulating the subsequent cascade of emotions that can result from emotionally turbulent interpersonal interactions;
4.Self-injury can become habitual for some (whether or not it is "addictive" in the physiological sense is still up for debate but that it has physiological effects which serve to immediately lessen distress is not);
5.Because of this, many individuals who self-injure are quite resistant to treatment in which stopping self-injury is a primary therapeutic goal until they are ready to try other strategies for regulating emotion and enacting agency.
For some self-injury is a spiritual act. As the father of self-injury research, Armando Favazza, wrote in his 1996 book, Bodies Under Siege:
Self-injurers seek what we all seek: an ordered life, spiritual peace - maybe even salvation - and a healthy mind in a healthy body. Their desperate methods are upsetting to those of us who try to achieve those goals in a more tranquil manner, but the methods rest firmly on the dimly perceived bedrock of the human experience (pp.322-232).
What can we do?
Parents and friends are likely to be the "frontline" when it comes to detecting self-injury in teens. Because of this, first reactions and follow-up are very important. Practicing what self-injury treatment veteran Barent Walsh calls "respectful curiosity" is really important. Respectful curiosity means not showing overly dramatic emotional displays like shock or horror and asking questions which assist you in getting important and helpful information such as "what do you notice is happening for you when you self injure?", "what kinds of things happen that make you want to injure yourself?", or "are there places on your body that you tend to injure more often than other places?"
While studies show that some chronic self-injurers tend to get better without therapy, many people really need professional help to open themselves to new ways of being in the world and with stress. Helping a child or friend get connected to individuals who can help them find someone to support them in this time is important (for additional resources on helping self-injurious friends and children: see www.crpsib.com and http://www.selfinjury.com/).
In terms of treatment, no one therapeutic approach has been shown to be effective, though Dialectical Behavior Therapy (DBT) is the most common and shows the most promise. In light of the core functions served by self-injury, it is likely that treatment approaches which contain all or most of the following strategies are likely to be the most promising:
* Actively surfacing of self-injury reinforcing self-narratives and concomitant processing and challenging of core beliefs (a la Cognitive Behavior Therapy or processes such as that recommended by Byron Katie's "The Work");
* Mindfulness methods which assist clients in making space for and accepting unwanted or uncomfortable emotions without needing to attach a story to the nature or meaning of the emotion (these strategies are particularly powerful when clients are helped to see that while emotions can be uncomfortable for a short while, they rarely last for long);
*Strategies for expressing emotions while present (again without narrative). Self-harm treatment veteran Matthew Selekman suggests some really innovative methods for employing core strengths and intelligences (e.g. musical, visual, tactile, etc..) in helping clients express emotion and mindfulness;
* Helping clients see that they may have a unique skill in their ability to pick up emotion from the environment but may need assistance in processing these emotional - with particular attention paid to cognitive attributions and regulation of subsequent emotional responses.
Ultimately, however, it is important to note that since self-injury can be very difficult to leave behind, there may be little more a support person can do beyond inviting contemplation, encouraging acceptance of emotion, and passing along strategies for simply being in the moment without having to attach meaning or story. By being able to hold an image of this for someone who injures, a parent, friend, or therapist holds space open for the possibility of change - whenever he or she who injures chooses to make it happen.
No matter how we understand the individual impulses for injuring or how it has come to be so prevalent, it is worth contemplating what its presence says about our culture and our youth. While the violence of the act renders it outside of most people's realm of understanding, youth who practice it are definitely products of the times and places in which they live. Contemplation of the ways in which self-injury reflects larger social trends and patterns will inevitably assist in effectively addressing why this particular form of self-inflicted violence has become so prevalent.
Elizabeth Lloyd-Richardson, Ph.D., is an associate professor of psychology at the University of Massachusetts Dartmouth and a licensed clinical psychologist who studies adolescent and young-adult health risk behaviors, with a specific focus on issues such as self-harm, obesity, and substance abuse.
