Understanding Self-Injury:
A Pain Too Deep
For Tears
Lynne E. Muller, PhD, NCC, LCPC
lmuller@bcps.org
Mary Ann Mathews
mmathews@bcps.org
2008
Self Injury
1. Who self injures?
2.Why do they do it?
3.What it is and is not.
4.How can we help?
“I needed to cut the way your
lungs scream for air when you
swim the length of the pool
underwater in one breath. It
was a craving so organic it
seemed to have risen from my
skin itself.”
Caroline Kettlewell
Skin Game
1
Self-Injury Terms
Self Inflicted Violence
 Cutting
 Self Harm
 Self Mutilation
SI Behaviors
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Cutting
Scratching
Abrading
Burning
Some forms of hair pulling
Biting
Inserting foreign objects into the body
Interference with wound healing
Ingesting toxins
Warning signs
• Unexplained frequent cuts or burns
• Wearing long sleeves or pants in warm
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weather
Avoiding swimming pools or the beach
Wearing thick bracelets to cover wrists
Having sharp objects in purse, book bag, or
bedroom
Difficulty expressing feelings
Withdrawal from close relationships
Self injury is the
intentional harm of one’s
own body without conscious
suicidal intent.
(Aldeman, 1998, Favazza, 1998, van der Kolk, et al., 1991)
What Self Injury is NOT
• It is not a suicide attempt
(attempting to feel better, not escape all
feelings)
• It is not usually attention seeking
• It is not a danger signal to others
NOT SUICIDAL BEHAVIOR
• “…self-mutilation is distinct from
suicide…A basic understanding is that a
person who truly attempts suicide seeks to
end all feelings where as a person who selfmutilates seeks to feel better.” (Favazza, 1998)
• Intention-does not intend to die as a result
of his/her acts. Intends to live.
Who?
• Roughly 2% (1-4%) of the population. In
some studies reported as high as 8 million
Americans self-mutilate.
• 30 times the rate of suicide attempts
• 140 times the rate of completed suicides
• May also suffer from eating disorders
• 90% who cut began as teenagers
Who?
• Typical profile
• Female
• Mid 20’s to early 30’s
• Began cutting as a teen
• Middle to upper class
• Intelligent, well
educated
• Perfectionist
Who?
• Males and females
• All races and socio-economic
levels
• Ages 15-50’s
• Not easily identifiable
Characteristics
• are often depressed, feel powerless or
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anxious
have low self esteem /negative body image
have difficulty expressing their emotions
verbally
experience difficulty with relationships
aim for perfection
often have negative body image
lack impulse control/suppressed anger
do not have a repertoire of coping skills
may have serotonin dysfunction
possible trauma
Abuse?
• Many who self-injure did not
suffer childhood abuse (Zweg-Frank, et.al,
1995, Brodsky, et. al., 1998)
• 50-60% suffered childhood abuse or
trauma. That means that 40-50% did
not (Favazza,1998)
Then Why?
• Invalidating environments (Lineham,
1993)
• Expression of private experiences and
feelings are not validated
• Feelings are trivialized, punished or
ignored
• Experience of painful emotions are
disregarded.
• Child’s interpretation of his or her
behavior is dismissed
In their own words . . .
2&3
“There are times when I hurt too deep for
tears, so I cut and it lets out some of the
hurt. It’s like when you see the blood
flowing out, the pain and fear are flowing
with it.”
“Watching the blood flow out makes me
feel clean, purified. It feels like
something bad or dirty is leaving with the
blood.”
In their own words . . .
4
“The stopped voice becomes a hand lifting knife,
razor, broken glass to cut, burn, scrape, pop,
gouge. The skin erupts in a mouth, tongue less,
toothless. A voice drips out, liquid…a voice
sears itself for a moment, in the flesh. This is a
voice emerging on the skin, a mouth appearing
on the skin. The body which could not be air on
the larynx becomes the stroke of a razor on
the breastbone or of a red-hot-knife-tip upon
the wrist…” .
Janice McLane (1996)
Why do they harm
themselves?
• To release intense feelings
• The physical pain may be easier to
deal with than the emotional pain
• To feel real, alive
• To exert some control
• Acting out self punishment
Cycle of Cutting
Cutting
Disassociation
Into the Void
Panic
Relief
Shame, guilt,
remorse, disgust
Mounting anxiety, anger
or self hatred, alienation
Muller 2005
In their own words . . .
5&6
“It’s like opening up a safety valve or
letting steam out of a covered pot.”
“Sometimes I cut just to make myself
feel something because I am just
totally numb.”
(In Strong, 1998, p.7)
Why?
7
“I felt like I was isolated from the
world, dead, with no emotions at all.
The blood told me I was alive, that I
could feel…Also I couldn’t cry, and
bleeding was a different form of
crying.”
(Lindsay in Strong, p.57)
What about the DSM?
Currently listed as a symptom
associated with a number of
mental health disorders
Some mental health professionals
are advocating for self injury to
be listed as a separate diagnosis
SI is often associated with:
• Borderline Personality Disorder
• Obsessive-Compulsive Disorder
• Post-Traumatic Stress Disorder
• Dissociative Identity Disorder
• Eating Disorders
• Substance Abuse
• Depression
DIAGNOSIS (Ferreira de Castro, et.al., 1998)
Self-Injure
Suicide Attempt
Major Depression
14%
56%
Alcohol
Dependence
16%
26%
2%
9%
Dysthymia
12%
7%
Adjustment
disorder with
depressed mood
24%
6%
Schizophrenia
Therapeutic Goals
• Encourage communication about self-
injury and relevant aspects of the
child’s life.
• Improve the quality of client’s life as it
relates to self-injury.
• Explore themes of guilt and shame.
• Diminish use of self-injury as the
coping skill when client desires to make
changes. (Conners, Rubin, et, al,2002).
Helping: What to Do
(Alderman, 1997)
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Learn about self-injury.
Talk about SI. Ask about it.
Be supportive. Show you care.
Acknowledge the effort to cope with very
difficult emotions
Set limits
Be available, but refer when appropriate
Don’t discourage self-injury
Recognize the severity of the distress
What Not to Do
• Be afraid to ask the question, “Do you self•
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injure?”
Make eliminating the behavior the primary
goal
Make a safety contract or use contracts as
a reward or punishment
Visibly monitor their injuries
Make him or her feel ashamed or guilty
about the behavior
“This is yet another secret I must hold to
myself because my therapist has given
me an ultimatum, either no more
hurting myself or we will have to
discontinue our therapy. So a little
distance comes between us now, a secret
that hold great importance which we
could both learn from, if I was able to
tell her…JML
Interrupting the Cycle
•Dispute irrational thoughts, feelings
•Triggering event
•Unbearable tension, anxiety
•Dissociation
•Self injury
•Relapse
Expressive Arts
• Journals
• Poetry
• Music
• Art
•Self-Injury Group
Respond to the following statements by writing “A” for
“agree” if you mostly agree with the statement or “D”
for “disagree” if you mostly disagree. Be ready to
explain your responses.
___Self-injurers are survivors.
___Self-injurers are weak people.
___Self-injurers are harming themselves to get
attention.
___Self-injurers are perfectionists.
___Self-injury is a type of suicidal behavior.
___Self-injurers are proud of their scars.
___Self-injury helps people cope.
___Self-injurers are more sensitive than most other
people.
Muller 2006
Self-Injury
•If my wound could talk it would
say_______________________________________________
__________________________________________________
________________________________________________
__________________________________________________
_________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Muller 2006
Taking Care of Yourself
• Monitor your own horror and
confusion
• Broaden your perspective past the
behavior to the intent behind it
• Seek consultation
• Get support for yourself
Care and Concern
• The capacity to derive comfort
from another is the single
biggest predictor of whether
traumatized patients are able
to give up their selfdestructive habits. (van der Kolk)
Care and Concern
• The development of a safe and
trusting relationship is vital for the
child to learn to sooth and care for
him or herself in a healthy manner
by internalizing their therapist’s
care and concern. (Strong, 1988)
Care and Concern
10
“_____ was the first to acknowledge that
maybe I was in pain, as opposed to ‘doing
it for attention’ . This affirmation of my
inner pain was a healing force. “ Shelley
Discussion
• Why the upsurge in self-injurious
behavior?
• Students who look for fist fights?
• Tattoos and piercing?
• Addictive?