harmless object into a sharp instrument to be used for self-harm. For example, Haley was hospitalized for suicidal ideation last spring. She was known on the hospital ward as a “cutter.” She was placed on suicide watch and almost everything that could cause harm was removed from her room. She was only allowed a marker and paper for journaling. Each day she sharpened the marker’s cap with her teeth, creating a pointed edge she used to cut her arms and legs when she felt the desire. She also gave herself paper cuts with the edges of the paper that was provided to her on a daily basis.
Hillary was Haley’s roommate. She took the hooks that held the curtains in place and used them to scratch her arms and legs before going to bed at night. In addition, she found sharp pieces of metal protruding from one of the legs under a table in the TV room and while still attached, used them to scratch her feet and ankles.
Clearly, if someone is motivated to self-injure they will find a way. The solution is not to try to take away every item that could be used for self-harm, since that would be next to impossible. Instead, the goal is to help the individual control the desire to self-harm, and to help them better tolerate the overwhelming feelings that are present in their lives (See Chapter 8).
The second most common form of self-injury is burning. Like cutting, there are a variety of implements an individual may use in order to burn herself, including a lighter, matches, cigarette, cigar, candle, stove top, and/or a piece of metal that has been heated by fire. Joey, 17 years old, has been burning different parts of his body since he was 11. He remembers the first time he burned himself in a game of chicken with his friend. He and his friend put a burning cigarette between their arms and the first person to pull away was bequeathed with the title of “chicken.”
Joey was determined to win the game. He recalls, “Winning made me feel tough. I was able to tolerate the physical pain longer than anyone else in my grade.” Joey developed a belief system in which tolerating physical pain made him strong and respected by his peers. He received positive reinforcement for being “the toughest kid at school.” Joey took great pleasure in challenging everyone he knew to the game of chicken.
When the game lost its novelty and others lost interest in playing, Joey began to play the game with himself. This time, he competed against the clock. How long could he stand the pain? The longer the amount of time that passed, the stronger and more powerful he felt. It did not take him long to realize that every time he was feeling powerless, he could burn himself and regain a sense of strength and self-confidence.
Escalation
Although cutting and burning are the most commonly reported types of self-injurious behavior, there are others. For example, the person may scratch, hit, bite, kick, head bang, and/or pull out hair. These secondary types of self-injurious behavior are often considered gateway behaviors to other, more severe forms of harm. In other words, someone may begin self-injuring using one of the methods listed above, and then move to a more severe form of self-injurious behavior. In the most extreme cases, an individual might break their bones, amputate a limb or inject toxins into their body. Although these behaviors are not common, they do occur.
There are various reasons why an individual might transition to a more severe form of self-injurious behavior. The two most cited reasons are: (1) to achieve greater mastery over distressful feelings, and (2) because superficial wounds do not provide the same “high” as do more severe wounds. In both cases, the individual increases the severity of bodily harm to achieve a specific goal.
Amber remembers making this transition. She clearly recalls her first time inflicting bodily harm. She writes, “Self-injury controlled my life for the better part of eight or nine months and what started it all I will never forget. I had a bad day at field hockey practice and I had finally had enough. Between pressures from school, my mom, field hockey and trying to deal with my own inner turmoil, I finally snapped. I came home so angry and so hurt; I didn’t know how to let it out. I could feel the tension growing inside me, just getting worse and worse and so I did the only thing that made sense to me. I began to hit myself with my hockey stick. I mostly stuck to my feet and ankles, but I hit my hands some too.
It didn’t make me feel better though. I needed more. So I went to the kitchen, got the sharpest knife I could find, and slowly ran it over my ankles. It was weird because I actually started to feel better. All that tension that was rising inside of me was released and seemed to flow out of me along with the blood. Hurting myself, at the time, was the only thing that made me feel better. From that time on, whenever something bad happened, I’d run right for the closest knife and start cutting.”
Accessibility
It is important to realize if a person engages in self-injury, it is likely that they will keep their instrument of choice accessible at all times. It may be hidden somewhere on their body, such as in a pocket, sock or shoe; or in a safe place nearby such as in their car, purse or wallet. Many self-injurers find it soothing to have the implement close by. Knowing they have a coping mechanism, or an instant “quick fix” for overwhelming emotions, is comforting and makes them feel at ease.
Joey recalls keeping a lighter with him at all times. He kept several in his car for easy access, he had one in every jacket pocket, and he hid one in his shoe when he knew the others would not be available. Sara knew her mother was aware of her self-injurious behavior and that she was terribly worried about her. Accordingly, Sara always tried to hide the behavior as well as the devices that she used to self-harm. Her instrument of choice was a razor blade. She recalls hiding them everywhere; in her purse, in her folders at school, under her foot in her shoe, and even in her hair when it was pulled up in a bun.
Elaine, a 35-year-old business executive, chose glass. She carried a piece of glass in her purse so that it was always with her. That way she could even slip out of an important business meeting and excuse herself to use the restroom, purse in hand, if tensions climbed too high.
Amber had designated places where she could go to cut, and carried a knife around with her wherever she went. She had one by her bed, and one in her desk, and if she went somewhere for the weekend, a knife came with her there too.
How is Self-Injury Discovered?
Self-injury is not a new phenomenon. Documentation of this behavior dates back to biblical times. The reason for the tremendous increase in publicity around this behavior in the past few years is directly connected to the increased number of cases reported in a variety of settings. Elementary, middle, and high school campuses are all identifying individuals who are engaging in this behavior much more frequently than in the past. Teachers are often the first to discover the problem and are often the ones who inform the child’s parent. This is how Sierra’s parents found out.
Sierra had just entered high school. The change from middle school to high school was not easy for her. Her mother described her as “a girl who strives for perfection in everything she does.” She noted that even as a little girl, she put a lot of pressure on herself. Unfortunately, her high expectations often led to disappointment.
Sierra agreed that if she is less than perfect in her eyes or in the eyes of others, she becomes overwhelmingly distraught. As a way to cope with this distress, she began beating herself up both figuratively and literally. She started scratching her arms and legs in the beginning of her freshman year. By mid-year, she added a routine of punching herself in the stomach every time she got less than a 95% on a test. Although this helped her relieve her frustration to some degree, the scratching and punching did not give her the release she was looking for. She began cutting herself, using an X-Acto knife. She found it ironic that it was the same knife she used to perfect her art projects at home.
One day, at the end of her freshman year, she was out at PE. She always wore long sleeves to hide
