What is Self-harm?
Self-harm includes any behavior designed to provide relief from emotional pain or emotional numbness through self-inflicted physical trauma. There are many methods of self-harm. The most common form of self-harm is cutting. Individuals use razors, knives and other sharp objects to scratch or cut their skin. Much cutting is done on the arms, especially because it is an easily accessible location. Many of these individuals hide the resulting scars with long shirts and bracelets. Other cutters seek attention from cutting and, therefore, don’t hide their scars, but openly show their wounds or scars.
Cutters sometimes cut in secret. The more hidden the scars are, the more severe the problem of self-harm tends to be. Individuals with self-harm issues also cut their breasts, thighs, back, hips, and legs. The cutting can be random or very ordered and sequenced. There can be large cuts, superficial scratches, or small marks grouped together (i.e. “cheese-grater” cuts).
Cutting sometimes intersects with other disorders. One severe cutter I worked with described a precise system for her cutting. She would cut herself four times, two inches apart between cuts. Cutting for her was a ritual that was reinforced by her struggle with obsessive-compulsive disorder.
Another prevalent form of self-harm is branding or burning. Individuals burn their skin with a hot object such as an iron, the stove, and/or matches. Rubbing an eraser against the skin can also cause a friction burn. Teens may utilize any of a variety of self-harm techniques depending upon their circumstances and emotional intent.
Causes of Self-Harm
Many, though not all, teens and young adults with self-harm issues have experienced some form of past trauma resulting in ongoing emotional distress. Instead of expressing this pain in productive ways – for instance by talking about it – many of these young people repress it and don’t experience it openly. Repressing intense emotions for extended periods of time can lead to emotional numbness. Immediately following a trauma, a temporary repression of emotions can be functional, but long-term this coping strategy can be costly. After conditioning oneself not to feel, it can become difficult to reawaken one’s emotions. Many young people who have coped by repressing feelings eventually have difficulty feeling anything. So, to feel, they cut. One reason teens may turn to physical pain as a coping strategy is that they are terrified of emotional pain, feeling that it might overwhelm them; as a result, they seek out physical pain so that they can feel something, but something much less threatening than emotional pain.
Others who self-harm do not repress their emotions. Instead, they experience the full intensity of painful emotions but have difficulty managing them. They may self-harm in order to redirect their attention from those emotions to a more manageable, controllable type of pain. This redirection allows them to temporarily disconnect from the emotional pain and achieve a sense of relief and mastery.
Biologically speaking, cutting the skin releases “feel good” chemicals called endorphins. These chemicals give the cutter a sense of relief. They feel better for a time, but this chemical release wears off. This can lead to an addictive cycle in which the young person cuts more and more frequently and deeply in order to experience the same emotional relief.
Usually, self-harm is not suicidal behavior. Many who engage in self-harm do not want to kill themselves; they just want relief from their pain. Sometimes the issues that motivate self-harm cause an individual to spiral into depression, which may eventually develop into suicidal ideation. In some instances, a careless act of self-harm can appear to be a suicidal attempt. For some, dissociation is a part of the cutting process; in such cases, the individual may not realize the extent of the harm they are inflicting until afterward.
Charlotte sat in my office with her eyes downcast. Earlier, her friends had run to my office in terror. They had noticed fresh wounds on her arms and they were afraid Charlotte was trying to kill herself. Without looking up, Charlotte told me that it was not that “big of a deal;” she seemed embarrassed by her friends’ concern. She said she had a habit of cutting her wrists with razors. She indicated that she was not trying to kill herself; it was just a way for her to deal with the problems in her life. When she had a bad day at school, she got emotional relief from cutting. When she had a disagreement with her foster parents, she would cut. When the boy she liked ignored her, she cut. Since she felt numb much of the time, cutting helped her feel alive and the fresh blood gave her a feeling of relief. Charlotte was only 14 years old but had been cutting for four years. Cutting was part of her daily routine and, she told me, it gave her great comfort.
Charlotte did not always hide her scars. Early on, she wanted to be “different” and have people notice her. She thought her scars were a badge of honor and set her apart from her peers. As I got to know Charlotte, I understood that she really wanted to stop cutting and that showing her scars was not merely an attention-seeking behavior, it was a cry for help.
Treatment for Self-harm
The best treatment for self-harm behaviors is helping the individual express and talk about their pain. As they do so, they can often gain perspective and understanding of the behavior. Some individuals have difficulty expressing themselves verbally, so talk therapy may need to be complemented by other forms of expression such as writing, drawing, painting, etc. The important thing is for them to release their pain in a healthy way.
Since self-harm behavior can be similar to an addiction, many individuals have intense urges to return to self-harm even as they try to recover. Teaching and helping individuals deal with these urges will be important in their treatment. It can be helpful to offer alternatives to the self-harming behavior such as using a stress ball, exercising, talking, finding a distraction, and seeking out the company of positive peers or adults.
Charlotte came to my office a few times a week for a year. Over time we developed trust and Charlotte began to share more deeply. She talked about her biological mother abandoning her, about the physical abuse she endured, about a family friend molesting her, and about the pain of being placed in foster care. She talked about the hurt these experiences had caused her. She cried and let out her pain. She shared her urges to cut herself and we set up strategies to help her. We talked about things she could do to soothe herself. She learned that she loved running, writing poems, and being with friends. Her self-harm behavior lessened as she learned to handle life’s stresses in more productive ways. She said being open and honest with herself, and sharing her pain with a trusted adult, helped her the most. Although she is still scarred by her past trauma, Charlotte has been able to move forward in healthier ways.
Self-harm is unhealthy coping strategy that some individuals use when dealing with emotional pain. Its causes can include past trauma, emotional pain, difficulty expressing oneself, and a lack of healthy coping strategies. There are many types of self-harm, although cutting is the most common. Being an adolescent female with a mental or emotional disorder puts one at a much higher risk for self-harm. Treatment includes teaching and encouraging the young person to engage forms of healthy self-expression. This work can take time and is most effective in the context of a safe and trusting therapeutic relationship. Although self-harm is difficult to overcome, it is possible with effective treatment. Many young people who have access to treatment live the rest of their lives free of self-harm.
Janette Davenport, MS, LPC is a therapist at New Haven Residential Treatment Center, part of the InnerChange family of adolescent treatment programs.