It wasn't until I had published this book [Psychological Self-Help] online in 1997 and was active on Forums in Mentalearth: Self-Help and Recovery from Self-Harm (you have to register first and please abide by the rules) that I learned that self-injury occurs among distraught anxious and depressed but functioning, educated women.

They taught me that self-injury can serve other purposes, such as reduction of distress. Since then I have read in recent publications about similar motivations.

One of the most detailed and readable articles about self-injury is in Look Beyond the Scars: Understanding and Responding to Self-Injury and Self-Harm.

This 2002 study interviewed in depth 24 self-injurers from all over England. I have relied quite a bit on their impressive report.

Painful life circumstances can lead to self-produced pain

In the kinds of self-injury cases I am concerned with here, there frequently is some very hurtful and disturbing condition in which the tendency to self-injure develops. You don't usually start with a method to hurt yourself; you start off with horrible circumstances and psychologically painful thoughts.

A very wide variety of distressing circumstances and feelings precede intentional bodily injury -- here are some examples:

Young people are sometimes emotionally abused and told they are bad, sinful, selfish, hurtful, hateful, uncaring, crazy, or weird. They may be blamed for their parents' troubles or divorce, etc. It isn't surprising they may end up feeling guilty, shame, self-hatred, and wanting to hurt or punish themselves.

Some have grown up in physically and sexually abusive families (beatings, threats & torture) and were called useless, stupid, ugly, slut, and a total failure; many were bullied by peers; some were raped.

Some responded with resentment, intense anger, and repressed rage; others adopted the negative evaluations and felt worthlessness, felt no one could ever care for them, and felt like a piece of trash. Some responded to being hated with a defiant attitude, e.g. "You can't make me change" or "I deserve to be abused but I can hurt myself more than you can."

Some wanted get back at the abusive person by hurting themselves via self-mutilation, i.e., showing visual signs of their feelings. Some physically responded to pain, punishment, and self-punishment by actually feeling better, something like having an adrenalin rush or taking drugs; others found that burning or cutting themselves numbs them to pain.

Others were feeling depressed, helpless and hopeless or were without feelings, almost like being dead. Some responded to self-injury while feeling dead with "The self-abuse showed me that I could feel and was alive."

Others felt alone, uncared for, scared, sad, not just neglected but utterly worthless, rejected by family and friends, placed in foster care, dumped by boy/girlfriend, etc. so, it felt better to hurt themselves and, in that way, escape the hurt from others.

Many were well aware they had seriously disabling psychological problems and felt weird, unable to cope, scared, helpless, and inferior. Still others felt out of control, couldn't do anything right, but were reassured by the courage they had when self-cutting, surprised at what injuries they could force themselves to inflict.

Also, some developed an eating disorder which countered the helplessness feeling; it meant "I can control something (eating, not eating, and throwing up)." Some had heard about self-injury from others and were impressed with their willpower.

This list of stresses is not exhaustive but it illustrates the kind of psychological-emotional conditions that set the stage for the development of self-injury reactions. Soon we'll see how that might happen.

Self-Injury varies in severity and serves very different purposes

It should be made clear, however, that not all people who Self-Injure start with a terrible traumatic crisis. Some may have simply had friends or relatives who injured themselves and learned the behavior that way.

Others who self-injure may have developed an unhealthy habit that helps them calm down: something like having a drink, eating, or smoking cigarettes or dope. In these kinds of cases, the injuries were not life threatening, maybe just a compulsion like pulling out hair, picking at sores, or sticking or hitting themselves.

This self-abuse may be a distraction, a way to release tension, to regain some sense of control over a situation, or to show others that they really are hurting.

Note: People who injure themselves do not necessarily have a mental health problem, especially if the physical damage is mild to moderate. For example, in a sample of about 2000 ordinary military recruits (60% males) about 4% had a history of self-harm.

That 4% scored higher on anxiety, depression, borderline, schizotypal, dependent, intense emotions, and fear of interpersonal rejection (Klonsky, Oltmanns & Turkheimer, 2003), but not high enough to keep them out of military service.

On the other hand, it is fairly common for Self-Injury to be combined with various psychiatric diagnoses.

Therefore, to understand this behavior in some people it is important to realize comorbid disorders may be involved, including: Depressive Disorder, Borderline Personality Disorder, Bipolar Disorder, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, Attention Deficit Disorder, Dissociative Disorder and others (see Diagnoses associated with Self-Injury).

Most of these additional diagnoses have a center core of intense emotions, impulsiveness, and irrationality. In addition, a different kind of self-injury occurs in the repetitive head-banging of autism and retardation. The most horrific mutilation, such as cutting off a limb, an ear, or self-castration, is usually in a very severe psychotic condition.

So, self-injury may range from a mild habitual coping technique to death or an extreme response to overwhelming stress.

Major Depression and Borderline Personality Disorders

Certain diagnoses have been studied because they are associated with frequent self-injury and suicidal behavior, namely, Major Depression and Borderline Personality Disorder.

One study (Brown, Comtois & Linehan, 2002) distinguished between suicidal self-injury and nonsuicidal self-injury in 75 Borderline women (over 50% were also diagnosed as having depression or anxiety).

The patients were about 30 and had self-injured an average of 6 times in the last year, so they were quite injury prone. The women who inflicted nonsuicidal injuries gave these reasons: (a) to produce some feeling (relief, a sense of control, an emotional high), (b) to express their anger, (c) to punish themselves, and (d) to divert their attention from painful situations or thoughts.

The main reason for self-injury given by the suicidal patients was "to make things better for others." That is interesting but you can be sure it is more complicated than that. They all wanted to reduce internal stress.

Another study of suicidal self-injury in Borderline Personalities attempts to clarify certain differences between potentially lethal behavior in people suffering Major Depression and those with Borderline Disorders (Gerson & Stanley, 2004).

Seriously depressed patients usually seem to be suicidal out of a deep sense of despair or self-disdain and seek the nothingness or peace of death. If their suicidal efforts fail, depressed patients may become even more depressed, hopeless, guilt-ridden, withdrawn and lethargic.

Gradually, if treated with medication and psychotherapy, they usually become less suicidal in time. In contrast, the Borderline patient (70% have self-injured) becomes suicidal more quickly in response to changing circumstances or relationships and they report feeling better soon after the self-injury.

This is more in keeping with their impatient, impulsive personalities.

Starting in late adolescence, they often cling to others but have problems with dependency and anger control, so their relationships may become highly emotional and unstable.

A major problem here is that Borderline personalities, who often self-injure in order to regulate their strong, rapidly changing emotions, run a serious risk of unintentionally dying because they underestimate the risk of death in self-injury.

Their therapists may also underestimate the risk, believing (correctly) their Borderline patients do not intend to kill themselves. Research has documented that single acts of self-injury are rarely lethal but when repeated over and over self-injuries can become a serious risk.

Be aware. About 10% of Borderline patients eventually die by suicide (Paris, et al, 1987). A cognitive-behavioral therapy, Dialectical Behavior Therapy, has been developed specifically for Borderline Personality Disorders (Linehan, 1993).

The creation of paradoxical behavior

Most of us hate pain and do all we can to avoid hurting ourselves -- our bodies have powerful reflexes and natural mechanisms to avoid injury and pain -- the sight of our own blood flowing out of a cut is alarming to most of us.

Some of the consequences of self-injury to some people are not what you would expect, namely, it can be an escape or venting mechanism, it may release built up emotions of anger, self-hatred, badness (blood letting can be seen as "letting the badness flow out of me").

Also, a dramatic self-injury can stop the downward spiral of depressive thoughts. Other people discover that the process of inflicting self-injury and pain takes their attention away from the most disturbing thoughts.

So, some people simply learn they can produce pain or a shocking injury that distracts them from depression, guilt, anger, and worrisome obsessions. As a result, some might start to self-injure repeatedly, ironically, to feel better (to come out of a terrible emotional slump).

This may seem odd, but it will not be surprising to people familiar with the concept of negative reinforcement (see chapter 4) in which the payoff or powerful reinforcement following some behavior is escape from an unpleasant situation. Reinforced self-injury can become a compelling habit.

Here is how one girl described her self-cutting from 13 to 16: "I was bullied and teased about my weight for two years and I couldn't stand it any more. I became so angry with my body that I tried to commit suicide just to punish myself. I wanted to cut my wrists but couldn't do that, so I cut my arms instead. I was calm as I did it. It felt I was finally in control of my life. It was a relief.

"The pain was intense but I focused all my attention on it. It proved I was still human and had feelings. From that first time, cutting became my preferred way to release feelings. When I got upset or angry, I'd just go to my room and cut with a razor or a sharp knife, then clean up the blood and wear long sleeves. I got to the point that I was cutting every day, it felt like I was an addict. I got a high cutting, a real buzz. But I also hated myself for doing it and I got scared as it became dangerous.

"Eventually, my Dad saw the scars and took away my knives and razors. It was terrible when people at school found out. They watched me and asked me why I did it. I really wanted to die then and took a big overdose. I've been in treatment at Mental Health ever since. I'll be graduating in 6 months; I'm doing OK in school. I'd really like to be a journalist."

The selection of a method -- injury or suicide?

Just as there are many causes of psychological pain, there are many ways to self-injure. Perhaps the most common method is self-cutting, most often on the arm. Another method is taking an overdose, i.e., taking drugs until you get sick or even lose consciousness, such as drinking until you pass out.

Note: the kind of harm done in self-injury attempts is usually different from suicide attempts. Firing a large bullet into your brain or jumping from the tenth floor is definitely suicidal. Cutting your arm or foot is not a common method for suicide but it is a common method to relieve the emotional hurt one is experiencing or to let others know they are very unhappy.

Some methods may serve either purpose, e.g., taking an overdose of drugs is a common method for both self-injury and suicide. Besides cutting and overdosing, self-injury includes burning yourself, hitting a wall, jumping from somewhat high places, hitting yourself, self-choking, and sometimes getting others to hurt you.

Most self-injury victims clearly differentiate in their minds between self-injury and making a suicide attempt (most self-harmers have had thoughts of suicide in the past but at any one time the intent is usually clear).

People wanting to self-injure may, of course, miscalculate the risks (and they are well aware of possible errors) but they often think of self-injury as a way of relieving their extreme emotional distress and, thus, reduce the chance of dying right now.

I don't want to imply that the distraught self-harmer always has a clear intent in mind -- to die or not to die. There are people who injure themselves seriously and are willing to leave the outcome up to chance or fate or to whatever powers they believe in.

To those of us who have never experienced the absorbed obsession associated with intentionally injuring our bodies and have never gotten emotional relief in that way, the whole idea may seem incomprehensible and, frankly, rather grotesque.

One's first thought may be that this is a thinly veiled suicide attempt; i.e., they are really trying to kill themselves but won't admit it. But as we understand the situation better, we realize that for many self-abusers the act is self-protective, not self-destructive. They don't want to die.

They want to deal with their troubles and unhappiness; they would like to find more constructive and effective ways of escaping psychological pain instead of self-injury. But until they discover better ways of coping, when they feel painfully distraught, the urge to self-injure returns. My Self-Help Forum friends helped me understand that situation. I appreciated that.

Like so much human behavior, self-harm is, at first, hard to understand. Each victim of self-harm is unique, has a different history, a different set of personal problems, and a different means of hurting him/herself.

There is sometimes a well remembered and understandable original experience with self-injury followed by a long history of using similar self-injury techniques over and over.

A therapist may believe (I think wisely) that the therapeutic task is more to develop some effective methods for dealing with the currently overwhelming emotional troubles rather than to analyze at length the childhood dynamics and reasons for starting to self-injure. But both routes might work.

How rare is self-injury?

There are few studies of the frequency and nature of self-injury. One study (BMJ, Nov., 2002, Volume 325, pp 1207-1211) of 6000 British 15 and 16-year-olds reported that 7% had deliberately hurt themselves sometime in the past (only 1 in 8 of that 7% had hurt themselves seriously enough to go to a hospital).

Another large study of teenagers reported that more than 10% had cut themselves sometime in the past. Hurting yourself may start at any period of life (as early as 6 or 8) but most commonly it starts in the turmoil years of 11 to 14. Wendy Lader, author of Bodily Harm, estimates that 1% of Americans use self-injury to deal with emotional distress but she says the rate is much higher among teens, especially females.

Why more females? Supposedly, according to Lader, partly because females tend to react inward when upset rather than outward -- they would rather hurt themselves than someone else and, besides, openly going into a rage isn't a very feminine thing to do.

Among people who have this tendency, how often do they self-injure? A few people may hurt themselves every day, e.g., pull out hair or pick at a sore, but more typically, say with cutting, it may be every few days.

Quite often there are several injuries close together and then a break for perhaps weeks or months. Such an irregular schedule makes it hard to know if you have finally stopped hurting yourself or not.

Other causal factors involved in self-injury

Personal characteristics and environmental circumstances sometimes set the stage for self-injury. For instance, people who observe or hear about self-injury very often think of the self-abuser as mentally disordered.

This social perception could well contribute to the self-injurer having low self-esteem. And low self-esteem increases the risk of self-injury.

The 2002 BMJ study mentioned above found that young females hurt themselves four times as often as males. For young women, the risk is increased if they have had family members or friends who self-harmed, been very depressed or anxious themselves, had low self-esteem, had abused drugs, or were impulsive.

For young males, high risk situations included having suicidal friends and relatives, using drugs, and having low self-esteem.

We have seen that self-injury usually starts while a person is extremely upset; then in a fit of anger or self-hatred or depression or a feeling that everything is going wrong, the person hits the wall or cuts him/herself or puts a cigarette out on her/his arm -- and finds the intense emotional stress is relieved.

This experience -- actually the emotional benefits of self-injury -- is remembered and may be used again whenever the stress becomes intense again.

Often, just the open, intense expression of feelings cleared the air and resulted in lessening of the stress. In some cases, the person clearly felt guilty -- felt they had been bad -- and the self-injury took the form of self-punishment.

For others, it wasn't self-punishment at all, but it just felt good to escape the hurtful feelings or to discharge their intense feelings. After emoting, some felt they were finally communicating and being heard; however, it would be a mistake to dismiss the expressions of genuine feelings during self-injury as being merely attention getting behavior.

Indeed, most self-injury is done in secret and kept secret. Yet, it can be a cry for help. And why not? Most self-abusers feel that no one understands them and no one cares.

The reactions of others to self-injury

Some people become concerned that a person who is so angry that they self-injure is dangerous to others. It is true that some self-injurers are angry with others, but they seem to usually cope with aggression by turning it on themselves.

Professionals do not ordinarily consider self-injurers to be a risk to others. Of course, if the self-injury behavior begins to include aggressive acts, such as bullying or physical threats, then one would rightly have concerns about the welfare of others too.

Naturally, friends or relatives are often upset by this behavior and bluntly urge the self-abuser to stop. Some people who self-injure feel some resentment of this and think "if my hurting myself doesn't bother me, why should other people be concerned? What's it to them?"

The answer is that watching or even hearing about self-abusive behavior is troubling to most people, especially if it could be permanent or lethal, if the aggression might extend to others, and if the observers do not realize that self-injury can be a method to allay the overwhelming stress.

Most self-abusers, however, in the course of time, feel that they would like to avoid using self-injury as a coping mechanism. If they can find other ways of soothing their emotional turmoil, the self-injury response will extinguish.

Other people -- friends, partners, and relatives -- often at least have negative feelings about self-injury; it doesn't immediately arouse sympathy. Instead, it often causes a conflict situation where the self-abuser is criticized and called weird or crazy.

Even experienced therapists may not have dealt with much self-injury before, so like others, they may be baffled by it. Besides, young people often do not take kindly to the comment that "you need to see a shrink" which is said more like an order or a demand, rather than gentle concerned encouragement.

How should one respond to a person who self-injures?

The simple answer is: with concern and respect, with a desire to understand and help, with no criticism, blame or negative comment. Some self-abusers appreciate getting to talk about their troubles, their feelings, and even their self-injuries.

Others feel they have been misunderstood, mishandled and neglected before, so "let's not talk about it." Sometimes they get tired of telling the same history over and over without getting help; sometimes they have been told that therapy will not be provided if they continue to self-injure (doesn't seem empathic, does it?); sometimes their helpers just seem uninterested, treat them like a child, or appear to have little time.

If these are the kinds of experiences self-harmers have had in the past, naturally if you are a newly assigned helper, they are not going to warm up to you right away. It takes a little time and a lot of genuine concern. They do want help.

In most cases, however, self-injurers feel they were or would be helped by support groups made up of other self-harmers. They don't believe that more statistical or diagnostic information about self-harm (in the form of the typical brochure in the doctor's office) would help them very much but they are interested in ways of coping.

Self-injurers often find that the agency service personnel and staff need more information about self-injury.

If you are a parent or a spouse of a self-abuser who also seems to be over-emotional, impulsive, unreasonable, provocative, and/or uncontrollable and is driving you crazy, she or he may have a Borderline personality.

If so, get the book, "Stop Walking on Eggshells" by Mason, Kreger, & Siever (1998). It may help you understand your loved one and be less upset by his/her roller coaster behavior. You need to take care of yourself and not get sucked into the loved one's turmoil.

How do people stop hurting themselves?

I must emphasize again that self-injury is both psychologically difficult to understand and dangerous to one's health. Therefore, an important and wise first move is to get professional help. I will mention self-help techniques but please seek therapy with an experienced, well trained practitioner.

WARNING: the following self-help methods, while intended to be helpful, may be described in some details that could trigger a self-injuring response. If you are in a mood to self-harm or if you are responsive to triggers, please do not read this section. If you are unsure of your self-control, please discuss how to reduce self-injury with your therapist soon.

The 2002 British study says the general answer about how people stop self-harming behavior is they start feeling better about themselves. How do they achieve that? They get their life in order -- somewhat. If they are completely "down," they find a place to live, a way to get food, a place to take care of their kids--real basic stuff (the threat of losing their children is a major stress -- and motivator).

They work through some of their intense feelings from the past and become more able to communicate with others, both to express things they don't like and to relate more positively.

Generally, among the very poor and disadvantaged in Britain, finding a supportive environment (living conditions and helpful friends) was a crucial step towards achieving an acceptable adjustment.

In their personal lives, some of the subjects in the British study who had reduced or quit self-harming had made use of self-help methods, e.g., a few had switched from hurting themselves to a somewhat controlled smashing of things, like breaking glassware or hitting objects with a bat.

Others had substituted using alcohol or drugs to relax or distract themselves instead of self-injury. Another approach is to cause pain in some less objectionable way, such as flipping your wrist with a strong rubber band or holding your hand in ice water or maybe just holding an ice cube.

A few people can substitute an imagined injury for an actual injury, e.g. by just thinking about cutting yourself or maybe marking with a red marker the place on your arm where you might cut and where the blood would flow, if you did it.

Instead of bodily hurting themselves, some people can vent their anger with physical exercise, e.g., do some real hard work, mow the lawn, lift heavy furniture, squeeze a pillow hard, workout at a gym, and in some of these ways feel less need to feel pain.

Breaking the chain of events early is possible (see chapter 11). Some had learned to detect early a troublesome downward train of thought leading to self-injury, and then they learned to consciously focus on distracting thoughts, such as watching TV, listening to music, taking a nap, or reading a magazine or book.

Still others found the chain of thought leading to more serious depression or self-hatred could be broken early by talking to supportive people, calling their therapist (or just thinking about topics for the next session), or posting to an online self-injury group (or imagining the conversation at the next support group meeting).

Also, a few found interesting activities to do, like relaxing and meditating (see chapter 12), going shopping or for a walk or a workout, writing their life story (see chapter 15), or doing drawings or art work to express their feelings.

More self-help ideas

Make a serious, effort (it will take therapy or weeks on your own) to understand these awful feelings that start and generate this whole process. Ask: "Why am I feeling so awful?" "Are my thoughts and feelings reasonable? If not, what unreasonable beliefs do I have that give me such a heavy emotional load and sap my self-esteem?" "How can I change these feelings and get a more realistic view?"

During some good times, prepare a list of things in your life that you appreciate, really enjoy, value, and feel grateful for. Use this list (keep it updated) as a handy reminder when depressed that there are good things in your life as well as bad things. Be sure to include your good traits, talents, good deeds, assets, beautiful parts, etc., showing you aren’t as bad as you sometimes think you are.

Procrastinate doing self-injury. Tell yourself to put self-criticism or self-injury off until later -- maybe "tomorrow." Most impulses lose their urgency when you put them off -- especially if coupled with keeping your mind on other things. The need to feel pain will diminish also because the deep depression, self-hatred, guilt or whatever has declined.

The environment is a powerful determinant of our behavior (see chapters 4 and 11). Hide away stuff you use to self-injure. Stay out of the room, chair, sink, or situation you usually hurt yourself in. Don't go there mentally or physically. If you are "triggered" somewhere (a room, a TV show, a book, a discussion, an idea), quickly get out of that situation and think about other things.

Develop a routine to easily use when feeling especially bad -- nurture, even "baby" yourself. Perhaps go for ice cream with a friend, take a long, warm bath, look at especially selected pictures of good times and people you love, play with a pet, develop special activities with your family, enjoy a nice romantic/erotic story, etc.

Sometimes people find it helpful to sign an agreement with someone to not self-harm without calling them first. For very distraught times, however, the contract may not be a strong deterrent.

The above methods have worked for at least a few people. No one method works for all people who self-injure. The methods that work are usually tailored for a specific person. I hope this long list helps you believe that you too can devise several techniques that might guide you away from deep depression and/or self-injury. Then try them out.

Changes needed in psychological services: Look beyond the scars

The British study group that I have cited several times found major deficiencies in professional care for the people who self-injure. I believe the situation in the US is similar. First, our institutions provide the same services for suicide and for self-injury, namely, medication and hospitalization or out-patient treatment.

But people who self-harm see traditional psychiatric hospital treatment as poorly understanding their needs (often negative and dismissive) and, thus, unlikely to give good service.

Needed are specific facilities and trained staff that would provide understanding, respectful, caring -- safe houses -- for a day or a few days; counselors specializing in self-injury; education and counseling for children, spouses, parents or friends involved; self-help instruction and self-help support groups; special attention to child care while families are broken up; and so on.

Some available literature

The major search engines will fetch many Web sites providing information and concrete suggestions for coping with self-injury. Note particularly PsychCentral and Healthyplace.com.

Other Web sites provide support groups, understanding articles, and suggestions for dealing with Self-Injury: Self-Injury: You are NOT the Only One and Self-help methods with self-injury are described in Stopping Self-Injury and in this article Self-Inflicted Violence: Helping those who Hurt Themselves by Tracy Alderman.

Two large Web sites cite many articles and review over 75 in print books in this area: Home-Health-Conditions-Self-Injury and Self-Injury Books.

There are a surprising number of books in print about this general topic, a couple by Clinical Psychologists and therapists: Alderman (1997) and Levenkron (1999), one by therapists who recommend extensive inpatient treatment (Conterio, Lader & Bloom, 1999), another by a psychiatrist (Favazza, 1996), and two by journalists who interviewed people with this compulsion (Hyman, 1999) and (Strong, 1999).

Any of the books can help you become aware and empathize with a self-harmer but I'd suggest one of the books written by a professional.

For references cited above please see the link to the Bibliography on the Table of Contents page.

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This article is an excerpt from Chapter 6 of the online book Psychological Self-Help, by Clay Tucker-Ladd, PhD.

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