When Feeling Better Hurts

The call comes out as an attempted suicide. Dad, screaming at the dispatcher, reports that his 22-year-old daughter has slit her wrists. The fire department is staging; it is a two officer call. On scene, the victim has numerous lacerations to both wrists with what appears to be a significant amount of blood loss. Paramedics cleanse the wounds and apply bandages, they advise you that the injuries are superficial and that the subject does not need transport to the hospital. The subject denies suicidal ideation or previous suicide attempts, explaining, "I'm a cutter, I don't want to kill myself, I do this all the time, it makes me feel better." If you are a school resource officer, the subject is 15, maybe even younger. There appears to be an epidemic of self-cutting at the high school. What exactly is deliberate self-harm? Why would someone intentionally hurt themselves? As an officer, what do you do at these calls?

By definition, deliberate self-harm refers (DSH) to the direct destruction of body tissue by an individual with resulting physical damage. Also, by definition, it is intentional injury to one's body without conscious suicidal intention. DSH is also referred to as self-mutilation, self-injury, self-abuse, self-inflicted violence and parasuicide. The behaviors are usually done secretly and privately. Self-harm may be planned and ritualistically performed, or it may occur impulsively and without forethought.

Types of Deliberate Self-Harm

There are three major classifications of self-harm.

  1. Major self-harm, such as castration and amputation of limbs, is usually associated with psychosis.
  2. Stereotypic self-harm, such as repeated head banging, is most frequently associated with mental retardation, autism or psychosis.
  3. The most common form of deliberate self-harm is referred to as moderate or superficial; it is the subject of this article. This type of self-harm includes
    • Cutting (72%)--the most targeted body parts are the upper limbs
    • Burning (35%)
    • Self-hitting (30%)
    • Interference with wound healing (22%)
    • Hair-pulling (10%)
    • Bone-breaking (8%)

Other methods of self-harm include scratching, skin-picking, deliberate overuse injuries, interference with wound healing, scraping, biting, and ingestion of sharp objects or toxic substances. While some individuals may self-harm only a few times, others have great difficulty stopping the behavior. Self-harm does not include behaviors where the primary purpose is sexual gratification (autoasphyxiation) body decoration (piercing or tattoos), religious ritualistic behaviors, or attempts to "fit in" or "be cool."

Epidemiology of Deliberate Self-Harm

For an estimated one to three million Americans, self-harm is a serious problem. Research has demonstrated that approximately one percent of the general population engages in deliberate self-harm. This statistic is likely to be grossly underestimated due to the secrecy and the stigma of the behavior. DSH tends to begin in childhood or adolescence; the typical age of onset is between ages 10 and 16. While the majority of people who harm themselves are females between the ages of 13 and 30, there are self-injurers of every age, gender, and economic group. DSH tends to peak between the ages of 18 and 24, and decreases as an individual enters his or her 30s and 40s. Princess Diana was a self-cutter; she also threw herself down a flight of stairs. The most common professions of self-injurers are teachers, nurses and managers.

Reasons People Self-Harm

The reasons why people self-harm are varied and often complex. Most self-injurers view their actions as a way to relieve intolerable tension resulting from interpersonal stressors. This is a temporary solution that they find effective. They find the behavior to be soothing--to feel pain on the outside instead of the inside. It is a way to cope with unpleasant feelings. It allows them to express anger towards themselves and/or others. They use it to punish themselves. Self injury may make them feel alive and real, which is sensed by experiencing pain or seeing evidence of the injuries. DSH can produce euphoria (related to endorphin release). It can also create a feeling of numbness, detachment, calmness or peacefulness. The behavior also allows the injurer to nurture himself/herself, while taking care of their wounds. Some injurers use DSH as a way to communicate what they cannot say with words; to tell people they need help, get attention, or even to request hospitalization. It may also be an attempt to get people to react to their actions; to get someone to care for them, make others feel guilty, drive people away, manipulate, or to avoid stress and responsibility.

Over half of self-injurers have a history of physical and/or sexual abuse, emotional neglect and/or chaotic family exposure as children or adolescents. Sexual abuse victims are the most likely to self-harm. The earlier the abuse began, the more likely the victims were to self injure, and their injuries tend to be more severe. Most self-injurers grew up in homes where others chronically invalidated their feelings. Communication with caregivers was met with erratic, inappropriate or extreme responses. The child's verbalized feelings were frequently dismissed or trivialized and/or even punished, leading to prolonged self-devaluation.

The overall clinical picture of self-injurers includes: a hypersensitivity to rejection, chronic anger (usually towards self), high levels of aggressive feelings, impulsivity, depression, anxiety, irritability, and maladaptive coping skills. Self-injurers tend to have poor affect regulation. They act on their current feeling state rather than considering their long-term goals.

Approximately 70% of those who engage in self-harm report experiencing little if any pain during their activities. Most of those who self-harm do know when to stop a session. After a certain amount of injury, the need is somehow satisfied and the individual feels peaceful, calm, soothed. Pain was rarely a factor in knowing when to stop the harm.

Risks of Deliberate Self-Harm

There are certainly risks associated with DSH. For some individuals, self-injurious behavior can have an addictive nature; the frequency and severity of the harm is increased over time in an effort to experience the same level of emotional relief as previously obtained (similar to alcoholics). It is estimated that one in five self-injurers has accidentally made a life threatening injury. Risks from cutting include dehydration and shock related to blood loss, as well as anemia. Infection is a common risk. Contagion is also possible if two or more self-cutters engage in the behavior with the same instrument. Scarring, sometimes grossly disfiguring, is often inevitable.

Treatment

Self-harm is embarrassing to the individual. Individuals tend to try to hide their behaviors and are reluctant to seek medical or psychological help. There are treatment modalities which have been found effective in treating DSH, especially individual therapy. Dialectical behavior therapy teaches self-harmers alternative ways to manage their emotions. Trained therapists can provide safer, different ways to communicate their feelings, self-soothe and cope. Other goals of therapy are related to appropriate conflict resolution, anger management and assertiveness training.

Self-harm is often associated with other psychological problems including mood disorders, borderline personality disorder, eating disorders, as well as, obsessive-compulsive, post traumatic stress, dissociate, anxiety, panic and impulse-control disorders. When self-injury is connected to untreated depression or anxiety, psychotropic medications can be extremely useful.

For Law Enforcement Officers

Assess the severity of the injury based on three factors: the extent of the damage, the level of medical intervention it requires, and the location of the wound. Call paramedics for assistance and/or transport if the subject needs emergency medical care.

The wounds from DSH are, by definition, not life-threatening and should not be prematurely interpreted as a suicide attempt or gesture. Ascertain from the subject if the behavior was suicidal in nature. Ask the following questions:

  • Do you have thoughts about killing yourself?
  • Do you have a plan?
  • Have you attempted suicide before? If yes, how and why?

Additionally, obtain third party information from significant others related to any recent suicide attempts or threats by the subject. If the person presents as an imminent danger to themselves, an involuntary psychiatric hold should be implemented. If they do not meet the criteria for commitment, ask the subject if they would like voluntary treatment. Parents and legal guardians can also seek voluntary treatment for a child or adolescent.

Psychiatric hospitalization is used as a last resort in the treatment of DSH. Hospitals provide an artificially safe environment, which can actually compromise the therapy techniques of understanding feelings and coping with the same in the real world.

Remember that physical and sexual abuse is a major contributing factor in DSH. Ask the subject if they have been abused, how, when, where, and by who. If you suspect abuse, make a report to Child Protective Services and send a copy of your report to the appropriate detective. If your department has a psychiatric team, refer the subject to them as well for follow-up.

Self-harm scares people, especially loved ones. The behavior is disturbing and difficult to understand. Encourage family and friends to educate themselves about the disorder. Demands and ultimatums will deteriorate the situation further. A link below will provide you with a comprehensive list of online resources you can share with subjects and their loved ones.

Remain non-judgmental; the behavior is effective for the subject. Encourage them to seek treatment, and reassure them that the disorder is treatable. A helpful hotline is 1-800 DON'T-CUT (800-366-8288).

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