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.
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.