What Do We Know About Self-Injury? (page 2)

What is self-injury?

Sometimes called "deliberate self-harm," "self-injury," "self-mutilation," "cutting," or "non-suicidal self-injury", self-injury typically refers to a variety of behaviors in which an individual intentionally inflicts harm to his or her body for purposes not socially recognized or sanctioned and without suicidal intent (Favazza, 1996). Self-injury can include a variety of behaviors but is most commonly associated with intentional carving or cutting of the skin and subdermal tissue, scratching, burning, ripping or pulling skin or hair, swallowing toxic substances, self bruising, and breaking bones. Tatoos and body piercing are not typically considered self-injurious unless undertaken with the intention to harm the body. Favazza (1996) identifies four primary forms of non-socially sanctioned self-injury: major, stereotypic, compulsive and impulsive. The first two forms are rare associated primarily with populations with significant psychiatric disorders. The second two are more common and are those most likely to be encountered in general populations of adolescents and young adults. Studies of self-injury characteristics in community populations show considerable variation in the frequency and forms of behaviors reported. For example, reported lifetime frequency varies dramatically – from single incidents to hundreds of incidents (Laye-Gindhu & Sconert-Reichl, 2005; Whitlock, Eckenrode, & Silverman, 2006).Similarly, although non-clinical samples often endorse a greater number of low-lethality forms than clinical samples (see Skegg, 2005), community studies show that individuals use a myriad of forms which vary dramatically in the capacity to cause tissue damage. Although cutting is one of the most common and well documented forms, over 16 forms have been documented in a college population (Whitlock, Eckenrode, & Silverman, 2006). Moreover, several studies have shown that the number of forms used by an individual varies significantly; from 1 to over 10 (Laye-Gindhu & Schonert-Reichl, 2005; Whitlock et al., 2006). Self-injury can be and is performed on any part of the body, but most often occurs on the hands, wrists, stomach and thighs. The severity of the act can vary from superficial wounds to those resulting in lasting disfigurement. Among respondents in a two college study, 1 in 5 self-injurious students indicated that they had hurt themselves more than intended at least once and 1 in 10 indicated that they had hurt themselves so badly that they should have been seen by a medical professional; only 6.5% had ever been treated for any of their wounds (Whitlock, et. al., 2006).

What factors contribute to self-injurious behavior?

In clinical populations, self-injury is strongly linked to childhood abuse, especially childhood sexual abuse (Brodsky, Cloitre, & Dulit, 1995; Kolk, Perry, & Herman, 1991). In addition, there is evidence that earlier, more severe abuse and abuse by a family member may lead to greater dissociation and thus greater self-injury (Brodsky et al., 1995). Self-injury is also linked to eating disorders, substance abuse, post-traumatic stress disorder, borderline personality disorder, depression, and anxiety disorders (see Yates, 2004, for review). The lack of empirical research in non-clinical populations reinforces the assumption that most or all of SIB is a product of pre-existing disorders, although more recent research in general populations of adolescent and young adults challenges this assumption (Kokaliari, 2004; Whitlock, et. al., 2006).

Is self-injury addictive?

Most self-injury researchers agree that self-injury does show some addictive qualities and may serve as a form of self-medication for some individuals. In our recent research with college students, a significant number of individuals who practice self-injury report having a difficult time controlling their urge to self-injure and interviews conducted for several of the studies associated with this project shows that many self-injurers describe both the immediate effect and overall practice as something with addictive properties. For example, many interviewees talk about moments of feeling the strong need to injure even when there is no obvious trigger and about having "self-injury free" hours or days. They also liken it to other drugs and talk about needing increasingly more or deeper injuries to feel the same effect. Recognition of the addictive properties of self-injury for some individuals is the basis for the "addiction hypothesis" noted by Grossman and Siever (2001) and summarized by Walsh (2005). The addiction theory suggest that self-injurious acts may solicit involvement of the endogenous opioid system (EOS) which regulates both pain perception and levels of endogenous endorphins which occur as a result of injury (Winchel & Stanley, 1991). Overestimation of the EOS can then lead to actual withdrawal symptoms which in turn lead to more self-injurious behavior.

Is self-injury contagious?

The seemingly rapid spread of self-injurious behavior among community populations of youth suggests that there may be a contagion factor at work. Indeed, self-injurious behavior has been shown repeatedly to follow epidemic-like patterns in institutional settings such as hospitals and detention facilities (Matthews, 1968; Taiminen et. al., 1998; Rosen & Walsh, 1989). For many, self-injury is a very private, hidden act. Over one third of respondents in our college study indicated that no one knew that they had self-injured and research confirms that the majority of habitual self-injurers discover it through private or accidental experimentation (Favazza & Conterio, 1989). However, anecdotal reports from adults working with youth in school settings report a fad quality to the behavior (Walsh, 2005; Whitlock & Purington, 2007; Heath, Toste, & Beettam, 2006), similar to that which occurs with eating disorders. Consistent with this, survey results of secondary school nurses, counselors and social workers suggest that there may be multiple forms of self-injury in middle and high school settings – some of which include groups of youth injuring together or separately as part of a group membership (Whitlock & Purington, 2007). Causes for the spread of the behavior in non-clinical populations have left many wondering what larger contextual factors might be at work. Our research suggests that the Internet and the increasing prevalence of self-ijnury in popular media, such as movies, books, and news reports (Whitlock, Powers, & Eckenrode, 2006; Whitlock, Purington & Gershkovich, in press) may play a role in the spread of self-injury.

Are rates of self-injurious behavior increasing in the adolescent and young adult population?

This is impossible to know because we have no idea how common self-injury used to be in community populations of adolescents and young adults. There is broad consensus, however, among researchers and those who work directly with young people that the phenomenon is increasingly popular. In a recent survey we conducted of college mental health providers and secondary school counselors, nurses, and social workers, virtually all respondents indicated that self-injurious behavior has becoming increasingly prevalent in the last several years (Whitlock, Eells, Cummings, & Purington, 2007; Whitlock & Purington, 2007). In a recent decade long longitudinal cohort study of adolescent self-injury in Great Britain, researchers found a 28 percent increase in the number of adolescents who presented for self-injurious treatment at a general hospital in Oxford, England (Boyce, Oakley-Browne, & Hatcher, 2001). Although no such study has been conducted within the US, the presence of self-injury in new and popular forms of media, such as in newspapers, have increased dramatically in the past several years (Whitlock, Purington, and Gershkovich, in press). A 2004 Los Angeles Daily News article report maintained that referrals for cutting and other forms of self-injury within the Los Angeles Unified School District increased dramatically in a one year period and the School District's suicide-prevention hotline fielded 600 calls on self-mutilation in a single 18 month period (Radcliffe, 2004). Whether the increasing attention to self-injury is due to the fact that more youth are actually engaging in the behavior, to increased likelihood to seek help, or to an increasing ability among service providers to correctly identify and report the behavior is unclear. It may very well be a combination of all three.

Detection, Intervention, & Treatment

Detecting and intervening in self-injurious behavior can be difficult since the practice is often secretive and involve body parts which are relatively easy to hide. Although experiences therapists in this area can offer advice based on experience, few studies which actually test detection, intervention and treatment strategies have been conducted. The suggestions which follow are those which evolve naturally from existing literature and from interviews with practitioners with significant experience in self-injurious behavior.

• Unexplained burns, cuts, scars, or other clusters of similar markings on the skin can be signs of self-injurious behavior. Arms, fists, and forearms opposite the dominant hand are common areas for injury. However, evidence of self-injurious acts can and do appear on pretty much every body part possible. Other signs include: inappropriate dress for season (consistently wearing long sleeves or pants in summer), constant use of wrist bands / coverings, unwillingness to participate in events / activities which require less body coverage (such as swimming or gym class), frequent bandages, odd / unexplainable paraphernalia (e.g. razor blades or other implements which could be used to cut or pound), and heightened signs of depression or anxiety. When asked, individuals who self-injure may offer stories which seem implausible or which may explain one, but not all, physical indicators such as "It happened while I was playing with my kitten." It is important that questions about the marks be non-threatening and emotionally neutral. Evasive responses are common. Not knowing how to broach the subject is often what restrains concerned individuals form probing. However, concern for their well-being is often what many who self-injure most need and persistent but neutral probing may eventually elicit honest responses.
• Schools, parents, medical practitioners, and other youth serving professionals all have an important role to play in identifying self-injury and in assisting youth in getting help. Unfortunately, lack of information on self-injury has hampered the creation of informational materials and/or treatment options. The S.A.F.E. Alternatives program in the Linden Oaks Hospital in Edward, Illinois is the one of the only existing inpatient treatment program specific to self-injury in the nation (see www.selfinjury.com). Moreover, while a small but growing body of evidence exists to assist those helping individual self-injurers, little literature exists to explain and address the environmental factors that contribute to adoption of the practice. For those who encounter self-injurious adolescents, creating a safe environment is critical. This can be difficult with youth who have suffered trauma or abuse. Drawing from a number of studies in this area, Kress, Gibon & Reynods (2004) maintain that structure, consistency, and predictability are important elements in forming relationships with self-injurious youth. Developing plans which emphasize a) taking responsibility for the behavior, b) reducing the harm inflicted by the behavior, c) identifying and more positively reacting to self-injury triggers and physical cues, d) identifying safe people and places for assistance when needing to reduce the urge to self-injure, and e) avoiding objects which could be used to self-injure (e.g., paper clips, staples, erasers, sharp objects) can help to reduce the harm associated with self-injurious practices and establish trust. This plan should serve to help stabilize the student and to provide structure and support until community-based counseling can begin.
• Avoid displaying shock, engaging in shaming responses, or showing great pity. The intensely private and shameful feelings associated with self-injury prevent many from seeking treatment. Self-injures often appear in emergency rooms only when self-inflicted wounds are so severe that they require medical treatment such as stitches or bone-setting. Because so little is known about self-injury, it is often misunderstood by medical staff members who provide the initial treatment. This misunderstanding may lead to extremely inappropriate treatment, such as stitching without anesthetic or intense feelings of frustration for the provider who asks, "Why is this person hurting him or herself?" Such reactions, if expressed in shocked or punitive ways, may reinforce the self-injurious behavior and its underlying causes and encourage the self-injurer not to seek care in the future. Self-injury is most often a silent, hidden practice aimed at either squelching negative feelings or overcoming emotional numbness. Being willing to listen to the self-injurer while reserving shock or judgment encourages them to use their voice, rather than their body, as a means of self-expression.
• Self-injury is, most often, not a suicidal gesture. It is important to differentiate between a self-injurious act and a suicide attempt at the outset since the two require different treatments. Mental health and counseling resources should be provided since self-injury is often a signal of underlying, unresolved distress. More long-term treatments may involve psychiatric and/or medical therapy.
• Self-injury serves a function -- explicitly teaching more appropriate coping strategies may be one way to provide self-injurers with adaptive alternatives. Self-injury is most common in youth having trouble coping with anxiety, depression, or other conditions that overwhelm their capacity to regulate their emotion (Chapman, Gratz, Brown, 2006). It is thus important to focus on enhancing awareness of the environmental stressors that trigger self-injury and on helping individuals identify, practice, and use more productive and positive means of coping with their emotional states. Focusing on elimination of the self-injury behavior without enhacing positive means of regulating emotion may simply lead to adoption of other self-destructive behavior, such as drug abuse. Drug therapy may help in some cases as well. Some patients using prescribed drugs for depression have found a reduction in the urge to self-injure while taking these medications (Walsh, 2005). Therapy may be useful in exploring the underlying causes of self-injury. A combination of the above treatments may significantly reduce or completely eliminate self-injurious behavior.
• Assess the safety of self-injurious practices. DiClemente et al. (1991) found that over one quarter of hospitalized adolescents who self-injured reported that they had shared cutting implements with others. Not only are the hazards of disease transmission or infection paramount, but bringing dangerous objects to school can lead to detention or suspension. Those who self-injure as well as those charged with detecting and intervening in self-injurious behavior need to adopt strategies for reducing the harm that can result as a consequence of sharing implements or using objects which might introduce infections.
• Assess level of group involvement. Anecdotal evidence of self-injurious practices among groups of youth is increasingly common. Group self-injury is often a means of group bonding and membership and, as such, is undertaken with aims other than reducing anxiety or coping with overwhelming negative feeling - motivations strongly associated with "lone" self-injurious practices. These differences in motivation are likely to necessitate differences in approaches to intervention and prevention. However, because there is also is evidence that self-injurious behavior can be contagious in institutional settings and anecdotal evidence that it is also showing contagious tendencies in school settings, identifying and intervening in group self-injurious activities is important. The possibility for serious unintentional injury or infection to occur and / or for individuals who begin to self-injure as a means of group membership to develop a dependency on the practice over time augments the importance of early intervention and prevention. Identifying who is involved, the nature and lethality of the self-injurious activities used, and the purpose served for individuals and the groups constitute important first steps in effective detection and intervention.
• Develop guidelines for detection, intervention and referral. Institutions, such as secondary schools and Universities should consider adopting formal guidelines for detecting and managing self-injurious behaviors. In a recent national study of University mental health staff, fewer than 1/3 of the respondents indicated that the institution for which they work possesses a set of guidelines for managing self-injurious or other depression-related behaviors but virtually all agree that it is something about which they would like additional information and guidance (Whitlock, Eells, Cummings, & Purington, 2006). In light of the fact that self-injurious behaviors appear to be increasing and somewhat "contagious", early detection and intervention is important. Specific resources which might aid with intervention and specific treatment strategies can be located on the resources page of this website.

Prevention

Virtually nothing has been written on effective ways of preventing the adopting of self-injurious practices. Indeed, this is an area badly in need of research. However, we can begin to craft possible strategies by acknowledging dominant reasons for initiating and maintaining self-injurious practices and from lessons in related fields, such as disordered eating.

• Enhance capacity to cope and regulate emotional perceptions and impulses. Inability to find alternate satisfying ways of coping with strong negative feelings is a highly consistent motivation for engaging in self-injury (Chapman, Gratz, & Brown, 2006). Indeed, one of the most common reasons for ceasing the behavior given in our recent student survey is the adoption of other coping mechanisms. It thus seems logical that effective prevention (and treatment) approaches will include a focus on enhancing individuals' capacity to cope with adversity. Indeed, this focus is one of the elements of Dialectical Behavior Therapy (DBT) - one of the more common and effective treatment approaches used with self-injurious behavior (Walsh, 2006). Broad agreement among mental health professionals that capacity to cope is declining in the general population of adolescent and young adults suggests that enhancing capacity to cope may also be a useful part of universal and targeted prevention approaches. Building on existing strengths and exploiting opportunities within institutional curriculum to help youth explore diverse methods of coping with negative feelings may help accomplish this objective.
• Enhance social connectedness. Those who practice self-injurious behavior also report high levels of perceived loneliness, less dense social networks, less affectionate relationships with their parents, and a history of emotional and/or sexual abuse (Yates, 2004; Whitlock et. al., 2006). They are also more likely to suffer from diminished self-esteem, feelings of invisibility, and shame. Indeed, feeling invisible and inauthentic are common themes among self-injurious students we have interviewed for our studies. Approaches in which adolescents and adults are aided in recognizing and building on existing strengths, in reaching out to and connecting way with others in an authentic and meaningful way, and in participating in activities which allow them to feel meaningfully linked to something larger than themselves may help to shape a more positive view of the self. This may ultimately lessen reliance on potentially damaging coping mechanisms.
• Avoid strategies aimed primarily at raising knowledge of forms and practices. Strategies aimed primarily at raising knowledge generally use single-shot or knowledge enhancement approaches to educate universal or targeted groups of youth about specific risk behaviors, practices, forms and consequences. In their review of eating disorder prevention strategies and research Levine and Smolak (2005) summarize research which suggests that single-shot awareness raising strategies (e.g., educational assemblies or workshops) are, at best, either not effective or only effective in raising short term knowledge and are, at worst, linked to increases in the behavior they intend to stop. Adverse effects were particularly evidenced in high school and college populations. Repeated and rigorous evaluation of the popular DARE program aimed at reducing drug use among youth has also been shown to be ineffective and, at worst, harmful (Lynam et al., 1999; Brown, D'Emidio-Caston, & Pollard, 1997). In many ways, these findings are consistent with common sense when regarded in the context of developmental processes - adult attention to specific risk behaviors, particularly if highly informative but of short duration or thoughtful follow-up, can be scintillating to adolescents interested in seeking adult attention or taking risks. Strategies which raise awareness about underlying factors (e.g. role of media or the cultural thinness ideal in promoting eating disorders) are not the same as those which simply educate about the prevalence, forms and practices associated with a specific issue and are likely to be more effective in positively raising awareness.
• Equip staff and faculty to recognize and respond to signs of self-injurious behavior. Although it may be unwise to share detailed information about self-injurious behavior with large groups of youth, adults likely to encounter adolescents or young adults who engage is self-injurious behavior do need to know signs and symptoms. They also need to know what to do if they suspect or know someone is using self-injurious practices. Toward this end, raising awareness among adults as well as establishing protocols for referral is helpful for those who work directly with youth.
• Focus on increasing staff and student capacity to recognize distress. As with many risk behaviors, our research shows that peers are most often the first to know or suspect that a friend is using self-injurious practices. As such, peers constitute the "front line" in detection and intervention. In light of the above recommendation to avoid awareness raising strategies about self-injurious behaviors with youth, we advocate concentrating effort on assisting young people recognize general symptoms of distress in their peers. Self-injurious behavior could be one of several categories of behaviors and perceptions assessed (mixing both positive and negative indicators avoids a soley deficit-based slant to findings) such as perceived wellbeing, eating disorders,life satisfaction, depression, relationships with adults, suicidality, etc. Additionally, while a few examples might be useful in explaining what is meant by self-injury, detailed description of forms could be avoided. In addition to educating about how to recognize distress, students could be encouraged to seek assistance and coached on specific strategies for getting help.
• Promote and advertise positive norms related to help-seeking and communication about mental and emotional status and needs. It often requires more than a program or two to change embedded patterns. The tendency for peers to show loyalty to friends rather than to adults is strong (and, in many ways, fundamentally socially adaptive). Peers with knowledge of a friend's dangerous behavior are may be unlikely to share that knowledge with an adult without concentrated effort by adults to alter adolescent and adult norms about help-seeking and communication -- particularly communication between adolescents and adults. Strategies focused on altering community norms in social support and help seeking have been shown to be exceptionally effective in suicide prevention in a general population of adults in the US Air Force (Knox et al., 2003). Whether this approach will prove effective with self-injurious and suicide-related behaviors in adolescent and young adult populations is the subject of current research between this researchers with the CRPSIB and Dr. Knox of the University of Rochester.
• Address sources of stress in external environment. The relationship between the sheer volume of stress or risk factors individuals confront and negative outcomes is well documented. Researchers have overwhelmingly shown that the more risk factors an individual confronts, the less like they are to thrive and the more likely they are to exhibit negative behaviors and attitudes (Sameroff, 1993; Rutter, 1989). The capacity to manage multiple stressors simultaneously is particularly difficult for children and adolescents who attempting to successfully meet core developmental needs as well. Although empirically impossible to verify, the argument that contemporary children and youth confront an increasingly complex and varied set of stress and risk factors when compared to previous generations is persuasive (Garbarino, 1995) and may be one reason for increases in rates of mental illness, including self-injurious behavior. If so, as Levine and Smolak (2005) argue for eating disorders, targeting environmental sources of stress may be a fundamentally more effective prevention strategy than targeting individual youth deemed to be at risk for self-injurious or other concerning behaviors.
• Educate youth to understand the role media plays in influencing behavior. Media has consistently been shown to affect child and adolescent behavior in profound ways (Huesmann, Moise-Titus, Podolski & Eron, 2003; DuRant et al., 2003). Examination of the possible role media plays in spreading the idea of self-injurious behavior is one of the projects undertaken as part of this study program. Our preliminary findings support the assumption that images, songs, and news articles in which self-injurious behavior is featured has increased significantly over the past decade. As Brumberg (1992) has argued for eating disorders, highly visible public displays of self-injurious behavior may add potentially lethal behaviors to the repertoire of young people exploring identity options. Helping adolescents and young adults become critical consumers of media may lessen their vulnerability to adoption of glamorized but fundamentally poor coping strategies.

References