impression that the hospital is a place of punishment. Second, a person will never be admitted to a hospital for misbehaving. The requirements for admittance are very specific and clear. A person will be admitted if they are at suicidal, homicidal or gravely disabled (meaning due to a mental disorder, the person cannot take care of even her own personal basic needs, i.e, food, clothing, shelter). Third, and perhaps most importantly, these kinds of threats make a child feel like they are a burden, and that their parents are trying to get rid of them. This leads to feelings of shame, guilt, hopelessness, and overwhelming sadness.
Sara was 13 years old when her mother asked her if she was suicidal. Her parents were aware of their daughter’s self-injurious past. Sara used to scratch her arms a few times a week when she was stressed out. This went on for approximately three months before she entered treatment. More recently, Sara’s parents noticed that she had fresh cuts on her shins. Sara told them that she fell walking up a flight of stairs at school. Her parents wanted to believe her since, to their knowledge, she had not harmed herself in over six months. However, something was different about their daughter this time. Sara was not eating or sleeping well. She was isolating herself from her friends and she was irritable with all family members. In the past, even when Sara engaged in self-injurious behavior, she seemed happy. In fact, her parents had no idea she was cutting herself until they got a call from her teacher. This time Sara’s mood was different. She seemed deeply depressed and her mother was certain that something was very wrong.
At first, Sara denied having any suicidal ideation. She told her mother that she was “in a bad mood” and asked to be left alone. Her mother was not convinced by her denial of suicidal feelings and re-approached her. She knew that self-injury was typically not an indicator of suicidal intent, but she also knew that her daughter could be self-injuring and suicidal at the same time.
Sara’s mother followed her instincts. She told Sara that if she was feeling distressed, she wanted to help. Sara opened up to her mother and told her the truth. She admitted to suicidal ideation and having a plan to kill herself that night. Her mother immediately took her to the local emergency room where she was placed on a 72-hour safety hold. Later that night she was transferred to an adolescent psychiatric hospital where she remained for two weeks. She received daily group counseling, individual therapy, and family therapy. Sara stated, “I didn’t want to be in the hospital, and every day I begged my parents to get me out, but I know it is what saved my life.”
Is Self-Injury High Risk or Low Risk?
For safety reasons, it is important to understand the difference between high-risk and low-risk forms of self-injurious behavior. Safety is always a concern when an individual is self-inflicting bodily harm. However, it is of the greatest concern when the risk level is high. It is imperative to intervene expediently when high-risk behavior is involved, such as in the case of the anonymous caller described previously. Deep lacerations requiring stitches, or third degree burns, are more likely to cause significant trauma or even death than superficial scratches and singed hair follicles.
There are two measures that determine whether a self-injurer is considered high risk or low risk. The first is the type of instrument they use. The second is the place on their body where they self-mutilate. Higher-risk instruments tend to include knives, razors, glass, and fire sources. Lower-risk instruments may include push pins, paperclips, staples, pencils, and rubber bands. Higher-risk body parts typically include wrists, neck, and inner thighs. Lower-risk body parts are generally forearms, upper thighs, stomach, and shoulders.
There are many consequences to higher-risk behavior. The most vital is obviously safety. However, another consequence, which is often overlooked, is scarring. Most self-injurers are left with scars on their body to indicate where they inflicted bodily harm.
Different individuals have different feelings about their scars. Some are embarrassed, some are proud, and some are indifferent. In any case, they are real and often permanent. Nadia writes, “The 400 or so scars on my body weren’t meant to mock me and scream – You Are a Screw Up! Look at you – years later! But this is exactly what they do.” She states, “It is ironic how the very thing that got me through is now the source of so much shame.”
Conversely, Nicole relates, “I am glad I have my scars. They tell a story about my life and are reminders of the struggles I have worked hard to overcome.” She is not ashamed or embarrassed about her scars and does not want them to fade. She states, “Losing my scars would be like losing a part of myself.”
Joey is indifferent to his scars. He says, “I am not ashamed and I am not proud of them. They are what they are and there is nothing I can do to change that. I knew I would be marking my body every time I chose to self-injure so I don’t concern myself with the scars now.”
Parents have their own feelings about their child’s scars. Most do not like to look at them and are devastated by what their child has done to herself. Parents often blame themselves that they let things get this far without knowledge or intervention. They worry that others will be quick to criticize, blame, and/or label if the scars are noticed. Therefore, parents often want to hide their children’s scars from others.
The individual struggling with self-injury recognizes how frightened, horrified, and even disgusted their parents often are when they see the damage that they have done to their skin. They are easily able to recognize when a parent is embarassed and ashamed of their actions. Although this may be a understandable parental reaction and a predictable consequence for the person engaging in self-injurious behavior, it is extremely upsetting to the person who is struggling with the problem.
Parents often try to hide their child’s problem with self-injury from others. Many are invested in keeping this a secret from others (see chapter 3 for more details). A big part of covering up the problem is covering up their child’s scars. When parents go to great lengths to hide the problem from others (even when well-intentioned), it can make the individual feel worthless, unloved, and unsupported. Many of my patients report that they feel like a disappointment to their parents and that they are “not good enough” in their parents’ eyes.
The following poem illustrates one patient’s feelings about her scars and her parents’ response to this very visible reminder of her struggles:
It wasn’t what you wanted When I pulled up my sleeves And exposed the deeply etched wounds of my past, Healing still, in memory. I remember your face as you examined my flesh You kept the disgust from your voice but it was there in your eyes. Still, you caressed the bitter reminders of years best forgotten: Angry scars patterning arms still weak and frail. With a saccharine smile you tried to reassure me that it was okay that you didn’t mind. But then you asked me to hide them, embarrassed by my pathos. I said I wouldn’t have it any other way, I pulled my sleeves down. But now, months later, I feel used and dirty because you with your savior complex asked for emotional nudity only to escape your own feelings of parental unworthiness And to showcase your perfect daughter with no problems.
The Most Common Reasons Why Individuals Self-Injure
There are several reasons that individuals self-injure. Understanding why a person engages in the behavior is very important in order to successfully treat the problem. Listed below are common reasons that individuals self-injure.
1. To Escape Emptiness and Feel Alive
Nadia shared a mental picture with me to help me better understand the reasons behind her self-injurious behavior.
