unaware that blood was seeping through her sleeve. Her English teacher noticed it right away when she raised her hand in class to answer a question. She was sent to the nurse who, in turn, sent her to the emergency room for stitches. The intense game of field hockey had re-opened a wound. Getting hit in the arm with the stick did not help either.
Upon entering treatment, Sierra tried to describe what led to her self-injurious behavior. She wrote in a journal entry, “At fifteen, before I have even finished my freshman year in high school, I already have a concept of what seems like immense pressure and stress. This is a feeling sewn deeply into me, a memory I can never erase. This pressure, coming from within, leads directly to my desire to self-harm. Although I cannot escape the memory, I can erase the tension and pressure that consume me in a given moment on a given day. Being the perfectionist that I am, I have always doubted myself, what I am capable of, and whether I am good enough. With help I am learning to break free of this habit, but the desire for perfection may always linger in the back of my mind.”
In addition to middle schools and high schools, universities, jails, and work settings are seeing their fair share of self-injurious behavior. Elaine, mentioned previously, writes, “I have been with the same company since I graduated from college and have worked my way up to vice president. I am proud of my accomplishments. It is not easy for a woman to make it in a man’s world, especially so early in life. I am a hard worker and I have good values. So why would I ever self-injure? The few close friends that know of my behavior ask me that question all of the time. They don’t get it. Almost nobody ever does. For me, it is not about hating myself or punishing myself or feeling pain. It is a way to express what I am feeling and relieve the tension that goes along with my very stressful job. I am worried about being in a relationship and starting a family. I certainly do not want to model this destructive behavior for my children. I just know that when I self-injure, I feel better. It is an immediate relief from the distressing feelings that I have on a regular basis.”
John is 22 years old. He spent one year in juvenile hall where he knew several kids who utilized self-injury as a coping mechanism. He never engaged in the behavior himself until he went to jail at age 19 for involuntary manslaughter. John is an alcoholic. He has been in and out of rehabilitation centers since he was 16. One evening, he got extremely intoxicated and blacked out. He doesn’t remember getting into his car, driving 55 mph in a residential neighborhood, and crashing into the side of a house. John killed a child who was asleep inside her bedroom. The first night he spent in jail, he began self-injuring as way to punish himself. He commented, “I could not hurt myself enough for what I did to that poor kid and her family.” The guards at the jail had to put John on a round-the-clock safety watch as a precaution to keep him safe.
Given the increasing number of self-injury cases, it is no surprise that medical and psychiatric professionals are inundated with patients seeking treatment for their wounds, scars, and psychological distress. Hospitals and doctors are often the first to identify self-injurious behavior. New and old scars are often observed when patients come to emergency rooms for treatment, or to their doctors’ offices for check-ups. In the past, these individuals were questioned about their injuries in attempt to determine whether they were being abused by another person. However, in recent years, questions regarding self-abuse have become much more prominent.
Brian is 17 years old and a junior in high school. His parent found out about his self-injurious behavior when he was taken to the emergency room for an unrelated incident. He broke his collar bone while playing in a football game at school. Brian explains, “I have always been described as ‘the popular jock that gets good grades and all the girls.’ Why would someone like me ever feel any pain, right? Wrong. I feel just as much pain and pressure as anyone else. It might sound weird hearing this from a guy, but society places too much pressure on teens to be a certain way and it’s not only the girls who feel it. Society says that in order for girls to be popular and successful in life, they must be thin and beautiful. In order for guys to be popular and successful, they must be intelligent, good looking, and strong. If a teen falls short on any of these traits, he or she is ostracized and isolated. It’s hard for me to meet all of the expectations that have been set by others. It is even harder for me to meet the ones I set for myself. When the tension becomes too much, I look for a way out. Self-mutilation provides me with that way.”
Why Does Self-Injury Feel Addictive
Self-injury is a coping mechanism that can feel addictive to the person who is doing it. When the individual self-injures, they experience a “rush” or “natural high.” This feeling stems from a physiological process; beta endorphins are being released into the brain. After the initial “rush,” the person finds herself in a peaceful and calm state of mind. This process is similar for individuals who exercise and experience the natural high that follows a good workout. These two feelings, the rush or natural high, followed by the state of calm, are what lead the person to engage in the behavior again and again. However, while the self-injurious behavior may feel very much out of the individual’s control, it is clearly something the person can control with proper treatment and intervention.
Self-injury is a behavior that is chosen to deal with intense distress. The individual feels that finding a solution, or at least a substitute behavior that does not include self-harm, is futile; a belief that is reinforced every time unpredictable, overwhelming feelings in daily life result in the decision to self-injure again. Elaine, for example, has struggled with self-injury for over a decade. She states, “Almost immediately, I was hooked. It was a hard habit to break because I liked the way it made me feel – completely at peace with myself. Any time I was sad, upset or angry, which was most of the time back then, I would cut to feel better.” Elaine cut herself every day, several times per day until she finally received treatment last year. She is now in recovery. She has not harmed herself in the past six months.
Many people who are recovered from self-injury still admit to feeling a desire to self-harm. It is not uncommon for these compulsions to be present for a long period of time following the last act of bodily harm. However, most individuals agree that, with time and intervention, the desires that they initially felt so strongly decrease in severity, duration, and frequency. Elaine, for example, reports that she had strong urges to self-injure for weeks after her last incident. She states, “At first it was all I could think about, but as time went on and I was able to tolerate my feelings better, my desire to cut decreased significantly. Now I rarely think about it at all.”
Feelings and Cognitions Associated with Self-Injury
Individuals who self-injure often experience feelings of worthlessness or “inner badness.” They frequently feel sad and “empty” inside. They may ruminate about death and dying, and ponder the usefulness of their lives. Nadia felt this way and relates, “I felt so empty inside that I often wondered if life was worth living. Self-injury helped me feel much more alive. It helped me feel something.”
The self-injurer is often very fragile even if she presents as someone who is self-confident and strong. Amber, age 16, explains, “I have been battling depression for almost two years now, but you would never know by just looking at me.” Most people see Amber as self-confident, beautiful, intelligent, and athletic. This led to her feeling misunderstood, invalidated, and unheard in many circumstances; all perceptions commonly cited by individuals who self-harm.
The way in which a self-injurer thinks and the way she feels seem to go hand in hand. Self-injurers characteristically have a particular thinking style. Their cognitions are focused on extremes, which is often referred to as “all or nothing” thinking. This dichotomous thinking style places the self-injurer at high risk for low self-esteem. Since there is no grey area within the dichotomy, the individual sees herself as either all good or all bad. With little room for partial gratification, it also sets the individual up for continual disappointment, particularly in relationships with others.
The self-injurer’s self-esteem
