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Many caregivers, both personal and paid, find themselves involved with individuals who sometimes self injure. Information and resources to guide the caregiver’s need to cope with their own discomfort and intervene in a supportive manner appear limited and focuses on making the person discontinue the behavior. Practices that help the necessary healing process must be developed.

Self injurious behavior is the intentional injuring of one’s body. The wounds are not intended to be life-threatening, often do not require medical attention, and are not intended to be manifestations of suicidal ideation or gesturing. The most common manifestation of self injury is cutting but also include burning, limb hitting and bruising, head-banging, picking at wounds, peeling the skin, deep biting, severe skin scratching, nail and cuticle biting, swallowing sharp objects, and inserting sharp objects or toxic liquids into the body.

The Child Study Center estimates that 1-2 million people in the U.S. intentionally self injure. This figure is likely an underestimate, representing only those who seek help. While much focus is given to injurers who are females, particularly youth, the reality is the behavior is exhibited by both sexes, all ages, races, cultures, sexual orientations and all socioeconomic backgrounds.

In some individuals, the self injurious behavior may be traced to neurological causes and the information that follows is not directed to those instances. However there is also a growing belief that self injurious behavior is a tool used to cope with feelings of intense helplessness. Individuals report self injury is a way to externally express internalized rage, can be a re-enactment of trauma, and that it is a coping strategy to manage overwhelming thoughts and feelings. Self inflicted violence is meant to soothe, alleviate anxiety, and increase a sense of power and self control.

One of the greatest risk factors is a history of physical emotional or sexual abuse. A traumatized child is robbed of the power to change or exert any control over what is happening, leaving him or her helpless in the face of overwhelming fear. Self injury allows the individual to take control over their own bodies, their own pain and their own nurturing and healing. It may relieve intense feelings e.g. despair, rage, terror and release internal psychic pressure. The body responds to the trauma of the injury by releasing endorphins which allows the release from the tension and stress.

Family, friends, and providers often react to self-injury with fear which may lead to frustration, anger, a sense of powerlessness and vulnerability. Caregivers often feel it is their responsibility to keep the person safe, and feel it is their own failure if the person continues to injure themselves, particularly if the person is a child or adolescent. The caregiver simply wants the behavior to stop.

Recognizing that many people engage in behaviors that are harmful, i.e. excessive drinking, smoking, eating habits, or excessive exercise may help the caregiver respond in a less controlling manner. Caregivers must learn to listen supportively without taking action. The importance of relationship cannot be over estimated. The caregiver must first attend to issues of power and control by allowing the person to make the decision about how and when to stop. Deciding not to force someone to stop injuring is a crucial step in supporting recovery. (Ruta Mazelis, editor of The Cutting Edge: A Newsletter for People Living with Self Inflicted Violence).

Most service systems, perhaps due to liability issues, focus on efforts to stop injuring at all costs. Interventions, such as forced hospitalization, restraint and seclusion, mandated medication, shaming or “don’t cut contracts” are coercive and re-traumatizing. These interventions mirror the original loss of power and control and ultimately do more harm than good. Interventions that fail to recognize the trauma often at the core of the problem, or the underlying struggle that self injurious behavior addresses are unlikely to promote healing.

Individuals who self injure recommend that to intervene in a supportive manner, ask the person how you might be of help and decide what to do based on the response. Individuals indicate talking with others who have healed from the need for self injurious behavior helps. As the deep emotional pain is acknowledged and released, and the person recognizes their strengths in survival and gains control over other aspects of their life, the use of self injurious behavior generally abates without specific behavioral intervention. Journaling, art therapy, relaxation techniques, visualizations, cognitive reframing and affect management are all recommended and useful. Trained therapists can provide safer, alternative ways to communicate, self-soothe, and cope but the individual must trust that they will not be at risk of involuntary treatment by revealing the behavior.
Domestic violence shelters can provide information and guidance in supporting someone who has experienced significant trauma.

Too often professional service systems react to self injurious behaviors by minimizing the risk of allegations of neglect by forcing the individual to discontinue the behavior. This practice may in fact cause more harm by re-traumatizing the individual. At the least the individual will learn to better hide the behavior rather than seek help. It is time best practice standards were developed that focus on the responses that best facilitate the person’s efforts toward recovery.

Last year SAMHSA began its 10 X 10 Wellness campaign utilizing a series of webinars to educate participants on trauma and trauma informed treatment. Perhaps their efforts will help identify best practices in addressing self injurious behavior. To learn more or register for upcoming webinars go to http://www.promoteacceptance.samhsa.gov/10by10/training.aspx

Aaryce Hayes – Mandt System COO

Source documents
Child Study Center, Vol 6, Number 2, pg 1 Nov/Dec 2001.
Ruta Mazelis, editor,The Cutting Edge: A Newsletter for People Living with Self Inflicted Violence, rutamaz@eohio.net
Facts for Families, No 73, Dec 2009.

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