Self-Injury Behavior: Emerging Trends and Treatment

by Elizabeth K. Carll, Ph.D.

Jennifer, an attractive 15-year-old girl, was referred for therapy after her parents learned of her bulimia, which had been occurring for more than one year. Jennifer’s best friend became worried with her increasing binging and purging, and confided her concern to her mother who then contacted Jennifer’s mother, as both families were friends. A few weeks into therapy, Jennifer revealed that she had been cutting her legs and arms when she became depressed and distraught. Already preoccupied with her appearance and weight, Jennifer’s boyfriend’s remarks, calling her fat when he became angry with her, further exacerbated her self-consciousness and poor self-esteem. Jennifer’s secret cutting behavior had become more prevalent in the last few months. However, as it was late fall she was able to hide the cuts under long sleeves and slacks. During the summer her mother had noticed cuts on her forearms, which Jennifer explained occurred when playing with her cat. Her mother advised Jennifer to stop teasing the cat.

The above scenario is quite typical of girls who engage in self-injury or self-mutilating behavior. Often they have been able to keep the behavior a secret from family and friends. More recently over last few years, there have been an increasing number of referrals specifically for self-injury behavior, not only my practice, but in my colleagues’ practices as well. Due to the dearth of research in this area, it is unclear whether this trend is a result of an increase in self-injury behavior, better identification of the problem, or a contagion effect, as girls who self-injure may have friends who do so as well. Most likely, this increasing trend may be related to all three factors. Typically the girls range in ages from 13 to early 20’s and are referred by family and school staff who are concerned about potential suicide and view this self-injury behavior as a cry for help. In reality, self-injurious behavior is not attempted suicide nor a cry for help, as adolescents and young women who self-injure are rarely suicidal.

Self-injurious behavior is less common among males and is often confused with difficulties in managing aggression. In actuality, self-injury is an attempt to control feelings of frustration, depression, and anger at one’s self. Punching a wall or breaking a window, until one’s knuckles are bleeding, are indicative of self-injury behavior.

Over the years I’ve observed self-injury behavior among individuals in treatment for trauma relating to emotional and/or sexual abuse as well as among adolescents with eating disorders, usually bulimia. More recently I’ve observed an increase in self-injury behavior unrelated to the above issues.

Therefore an in-depth discussion about the nature of self-injury behavior during the initial consultation is very helpful to reduce anxiety for the family. During the initial consultation I include the following information and also provide written information (a fact sheet that I have written) to take home.

What is self-injury behavior?

Self-injury, also referred to as self-harm, self-mutilation, or cutting occurs most frequently among adolescent girls and young women. Self-injury occurs as a maladaptive way of coping with intense feelings of anxiety and depression. The emotions seem overwhelming and result from stress, trauma, and loss. The self-injury is usually in the form of cuts or burns on the arms, legs, and abdomen. While less common forms include pulling out body hair and punching walls. Often adolescents may feel disconnected from their family and friends.

Among teens there has been an increase in the prevalence of multiple body piercing, such as eyebrow, nose, and belly button rings. However, these piercings are viewed by teens as positive ways of enhancing one’s appearance and are unrelated to self-harm behavior. Parents, however, may view this as self-mutilation.

The self-injurious behavior is not an attempt at suicide, as adolescents and young women who self-mutilate are rarely suicidal. Rather the act of cutting or burning is used to numb what is perceived as unbearable tension related to anger, depression, anxiety, and/or guilt. The cutting provides temporary relief by blocking out distraction and painful feelings. The physiological response to cutting and burning is an increase the level of endorphins in the bloodstream resulting in numbing or even a pleasurable sensation.

Warning signs:

Treatment

A combination of individual and family therapy is helpful with focus on understanding the reason for self injury, developing appropriate coping strategies to deal with stress and related problems, improving family communication and fostering a sense of connectedness for the individual, and facilitating family awareness as how to best help the family member who is injuring herself/himself.

In a small percentage of cases, and adolescents may not be amenable to family therapy. It has been my experience that often an adolescent, trusting that I would respect confidentiality, is relieved to have me meet with his/her parents separately. Doing so reassures the parents as to progress, provides an opportunity to answer questions as to the course of self-injury behavior, and reduces their anxiety. As a result parents are less likely to be hyper vigilant and closely monitor their child’s behavior. This is a welcome relief for the adolescent.

It is important to recognize that progress in the reduction of cutting behavior may be slow and it is necessary to work toward incremental steps. Working toward the goal of reducing the frequency and severity of self-injury helps to demonstrate to the individual that they can develop control over this behavior. At the same time it is important to accept that the self-injury behavior is viewed by the individual as an effective way of coping with intensely painful emotions. Adolescents in particular, are hypersensitive to any perceived criticism of self-injury as a coping behavior and view this as a lack of understanding on the part of the therapist. As is the case in treating post-traumatic stress, the pacing of therapy is an important component in the treatment of self-injury behavior.

Resources

Fact Sheet:

Carll, E.K. 2002. Information About Self-Injury. Available upon request from ecarll@optonline.net.

Books:

Alderman, T. (1977). The scarred soul: Understanding and ending self-inflicted violence. Oakland, CA: New Harbinger.

Clarke, A. (1999). Coping with self-mutilation: A helping book for teens who hurt themselves. Center City, MN: Hazeldon.

Connors, R. (2000). Self-Injury: Psychotherapy with people who engage in self-inflicted violence. Northvale, NJ: Jason Aronson.

Conterio, K., et al. (1999). Bodily harm: The breakthrough program for self-injurers. New York: Hyperion.

Farber, S. K. (2002). When the body is the target: Self-harm, pain, traumatic attachments. Northvale, NJ: Jason Aronson.

Hyman, J. W. (1999). Women living with self-injury. Philadelphia, PA: Temple University Press.

Miller, D. (1995). Women who hurt themselves: A book of hope and understanding. New York: Basic.

Smith, G., et al. (1999). Women and self harm: Understanding, coping, and healing from self-mutilation. Routledge.

Strong, M. (1999). A bright red scream: Self-Mutilation and the language of pain. Penguin USA.

Elizabeth Carll, PhD, is a clinical and consulting psychologist in private practice in Long Island, New York, with interests in stress and trauma, health psychology, conflict and violence, and mass media. She is the author of Violence in Our Lives: Impact on Workplace, Home, and Community. Dr. Carll is the president of the Media Psychology Division of the American Psychological Association (APA) and chairs the Committee on Violence and Disaster of the International Division of the APA. She can be contacted at (631) 754-2424, ecarll@optonline.net.