Writing, Reading, and Healing: Research on Self-Injury
In Cheryl Rainfield’s book Scars, Kendra uses cutting as a coping mechanism when memories of her childhood sexual abuse overwhelm her. Cutting is, of course, not a healthy coping mechanism, but it is certainly an effective one. As a psychology student, one of my main research interests was the differentiation between self-injurious thoughts and suicidal-ideation. Self-injury, while dangerous, is typically a method of holding on to life, while suicide is a means of ending it. One of Rainfield’s goals in writing Scars was to inform people about self-injury so that they will hopefully be more understanding and less judgmental. Along the same lines, I’d like to share some of my research from college. It is admittedly a few years old, and it contains some generalizations that are by no means applicable to everyone who self-injures, but I hope that it will still be informative.
The mind and body are one. Harm to the body results in damage to the mind, to the soul. As Alice Miller said, “Our intellect can be deceived, our feelings can be numbed and manipulated, our perception shamed and confused, our bodies tricked with medication. But our soul never forgets. And because we are one, one whole soul in one body, someday our body will present its bill” (Strong, 1998, p. xx-1). It follows, then, that millions around the world display their internal suffering through bodily self-harm, their skin a tabula rasa on which their pain is drawn.
Not a new concept, self-harm was referenced as far back as the New Testament Gospel of Mark, in which a man cut himself with stones (Strong, 1998). In research, however, such behavior has received little attention until recently. Research institutions have perceived self-harm and the traumas that precede it as unscientific. As a result, funding for investigations regarding self-harm are few in number, particularly with regard to the biological components. While nothing in psychology is ever fully proven, the scarcity of information pertaining to self-injury suggests that it, in particular, should be taken with a grain of salt.
Self-harm, also known as self-mutilation and self-injurious behavior, is one’s deliberate destruction of his or her own body tissue, with an absence of suicidal intention (Nock and Prinstein, 2005). It can be divided into a variety of categories, including major, stereotypic, and superficial self-mutilation. Major self-harm is characterized by infrequent, but large acts, such as eye enucleation, castration, and limb amputation. These are typically associated with psychosis, transexualism, or intoxication from drugs or alcohol. Additionally, they are often connected to religious and sexual themes, e.g. removing an offending eye or hand. Performed more commonly by individuals with mental retardation, autism, or Tourette’s Syndrome, stereotypic self-harm entails repetitive and sometimes rhythmic head banging, hitting, and self biting. The last and most common category, superficial self-mutilation, refers to compulsive acts, like hair pulling, skin scratching, and nail biting, as well as episodic and repetitive incidents of skin cutting, carving, burning, needle sticking, bone breaking, and wound healing interference (Strong, 1998). Though all of these different kinds of self-injury exist, cutting and burning are two of the most prevalent methods. For the simplification of this essay, the terms self-mutilation, self-harm, self-injury, and cutting will be used interchangeably.
Within the definition of self-harm, the distinction between mutilation and suicide is of great importance. Both self-harm and suicide are serious issues, but the former occurs at a rate of 30 times higher than attempts at the latter, and occurs 140 times more frequently suicide completion. A reported two million Americans intentionally cut or burn themselves each year (Strong, 1998). This ranks self-harm higher in importance based on frequency of occurrence, if nothing else, and notably categorizes self-harm and suicide as two discrete acts. According to a study by Gutierrez and Muehlenkamp (2004), less than half of those who self-mutilate have suicidal ideation, and few of these people report having suicidal thoughts prior to or during the harming process. Armando Favazza clarified the disparity between self-harm and suicide, saying, “Ultimately, [self-harm] celebrates not death but rather the will to live. It chronicles the struggle of humankind to maintain equilibrium” (Strong, 1998, p. xiv). While self-injurious behavior is done with an inherent risk of death, one must remember that it is performed with the motivation of coping with life, rather than ending it.
Self-mutilation is not restricted to any one type of person. Adolescents, though, injure themselves at a more alarming rate than any other group. (Note that three times as many females as males self-harm [Lowenstein, 2005], thus subsequent references to people who self-injure will label them as female.) The typical individual who self-harms starts hurting herself at around the age of 14, and continues to do so on and off for 10 to 15 years (Strong, 1998).
The primary questions to address are what elements form a developmental basis for self-harm in general, and what external and intrinsic factors contribute to the high rate of self-injury in adolescence relative to other age groups? Further, how do adolescents who self-mutilate differ from others their age? Is there a particular age at which psychologists can best predict future self-harm?
Like people who self-harm and the methods they use, reasons for self-harm are varied. Self-mutilation is a tool used to gain relief from emotional pain, to receive attention and thereby help, to influence someone, to achieve control when one feels none, and to prove that one is alive through the sight of blood. Half of all female cutters claimed that they wanted to punish themselves. Most people become frustrated with themselves or others at some point in time, but manage to cope without self-injury. The risk for self-harm is magnified for individuals from homes with separated or divorced parents, marital discord, and young or poorly educated mothers (Skegg, 2005). People who experience anhedonia, a loss of pleasure in acts that once were pleasurable, as well as other forms of restricted affect, emptiness, and detachment, are more likely to self-harm in order to experience the positive reinforcement it provides through the sensations and feelings that it offers (Nock & Prinstein, 2005).
Biological factors, too, contribute to whether or not one uses self-harm as a coping mechanism. Low concentrations of f-HIAA, a serotonin metabolite, have been found in the cerebrospinal fluid of self-harming individuals. Another measure of altered serotonergic function, blunted fenfluramine-stimulated prolactin release, has been related to the seriousness of self-injury (Skegg, 2005). Treatment of people who cut with SSRIs, serotonin reuptake inhibitors, has been effective (Strong, 1998). This finding is in agreement with the existence of low serotonin levels in those who cut. Several sources offer these biological findings as significantly correlated with self-mutilation. While this may be the case, it is also possible that the real association is that of serotonin imbalances with depression, thus indirectly connecting serotonin and cutting through a more direct link of depression and self-harm.
While one typically has an innate desire to avoid pain, mystifying the self-mutilation process, biology helps to demystify the act. Most people who self-injure feel little or no pain when they harm themselves. Mark Schwartz describes the feeling of cutting as something of a multi-functional coping mechanism to treat any variety of mood, saying, “For somebody who is high as a kite it brings you down, it numbs you. But cutting is also a stimulant. For somebody who’s numb, it stimulates them” (Strong, 1998, p. 59). The release of endogenous endorphins may block the pain that one would expect to occur while cutting (Nock & Prinstein, 2005), which would explain the addiction and withdrawal cycle that 71% of people who self-mutilate feel, according to a study by Favazza and Conterio. Enkephalines, opiate-like chemicals that are related to endorphins, are found in those who cut with the most recent and severe mutilation experiences. The presence of these narcotics was reinforced by the reoccurrence of pain when the chemicals were cut off through injections of naltrexone, an opiate blocker (Strong, 1998). Other biological changes associated with the script for self-mutilation include decreases in respiration, skin conductancy level, and heart rate (Andover & Gibb et al., 2005). Like Pavlov’s dogs that salivated at the promise of meat, people who cut may experience a conditioned response built up by creating bodily sensations following the numbing they experience due the heightened level of opiates in their systems.
Of all factors associated with self-mutilative behavior, childhood abuse accounts for the majority. Fifty to sixty percent of those who self-harm were physically or sexually abused as children (Strong, 1998). These children grow up being told that they should stay strong; they were not allowed to express themselves. Though full of hurt from their tragic experiences, abused children spent so much time repressing their feelings that they no longer know how to express them appropriately, and have difficulty forming relationships with others who might help. David Frankel wrote that kids from non-abusive homes “internalize a sense of parent they can call up from inside themselves for comfort in times of distress.” Children who were abused, though, do not have that same internalized parent to help them through their troubles, “what they call up is a Mom who wishes they were dead and a Dad who wants to sleep with them” (Strong, 1998, p. 42). Unable to deal with their problems and emotions properly, “sadness seems annihilating, rage often feels murderous” (Strong, 1998, p. 44). The parent that they have internalized becomes mixed in with their sense of self. Abused individuals who self-injure may not be able to distinguish between self and other, inside and outside. Some cut themselves in order to punish their abusive parent; others attack themselves as a way of dealing with the parent who did not abuse them, but stood by and did nothing (Strong, 1998).
People who cut might respond to their abuse by self-harming for other reasons. Rather than trying to punish their parents, some might be punishing themselves. Abused children often feel they deserved their mistreatment, should have done more to stop it, and consequently believe that they are bad people. This sense is magnified in children who liked the attention they received during abusive incidents, as it was often the only attention they got. As severely troubled are those who felt betrayed by their bodies, which had innate positive reactions to sex. The negative associations that result from such experiences might cause people who self-harm to disfigure themselves in ways that make them less visually appealing to potential abusers, or to equate love with pain. These children want to destroy themselves, body and soul. They do so, though, in ways that they can control. Their self-harm allows them to act out their childhood trauma in manageable doses, performing the roles of victim, perpetrator, and caretaker, all while knowing that no one can cause them as much pain as they can give themselves (Strong, 1998).
The developmental trauma of inattentive parents was echoed in Harry and Margaret Harlows’ monkey study. They found that lab monkeys separated from their mothers in their first year of life became excessively fearful and aroused. The monkeys bit themselves, banged their heads, slapped their own faces, and sometimes attempted to chew off limbs. Increases in stress had a positive correlation with increases in self-harm. The hyperaroused and irritated monkeys grew calmer following their self-injurious behavior. The Harlows believed that the babies became overwhelmed by fear because they lacked the internalized sense of security and affection that develops with warm parents (Strong, 1998).
Yet, the question remains: Why does self-harm occur so predominantly in adolescence? According to a 1995 study by Nock and Prinstein, the rate of self-harm in adolescents is 14 to 39% in community samples and 40 to 61% in inpatient samples, drastically different from the adult rate of four percent in the general population and 21% of adult inpatients. This is no coincidence. Adolescents face a rollercoaster of social, cognitive, and physical changes.
Adolescents undergo a conflict between continuing dependence on their parents, and a new sense of interdependence with their peers (Anderson, 2000). The negative effects of new peer relationships can be seen in the clustering of adolescent self-harm. Friends’ behavior may prime adolescents’ familiarity and comfort with the concept of self-mutilative behavior. 82.1% of adolescents reported self-harm among at least one of their friends in the previous year, with an average of 4.11 incidents, thereby setting the stage for an epidemic of self-injury (Nock & Prinstein, 2005). The spreading nature of this self-harm contributes to the larger number of adolescents who self-harm relative to other groups.
Cognitive immaturity also results in the drastic measure of self-harm as a coping device. Groholt and Hjelmeland (2005) noted that adolescents have a reduced ability for abstract thinking and problem solving. They attributed this to adolescents’ lack of experiences with difficulties, as well as the recently developed ability of recognizing that something has both positive and negative attributes. Like any skill with little practice, there is a period of instability and inaccuracy. This instability is heightened during times of stress, leading to an increase in black and white thinking during these periods. Groholt and Hjelmeland’s explanations of cognition are valid; however, the remainder of their study comparing adolescent and adults who self-harm is challenging to accurately interpret, as they seem to view self-harm and suicide as one and the same, despite abundant evidence to the contrary.
Impulsivity is another cognitive, decision-making feature noted in adolescents. Immediate emergencies, rather than long-term planning, motivate self-mutilative behavior. These acts are usually contemplated for less than a few minutes, and without the influence of alcohol or drugs (Nock & Prinstein, 2005). The impulsivity of those who cut is not surprising, given that people who self-mutilate often take their lives five minutes at a time. Rex Cowdry explained that people who cut have a short “time-horizon.” They live in the present, thinking that they have always felt as bad as they currently do, and believing that nothing will ever get better (Strong, 1998, p. 56). People who cut show a lapse in long-term cognition, with a focus on the emotions of the here and now. They do not spend these passionate moments planning their mutilation. Rather, they go directly from stimulus to response, possibly without even thinking through what triggered their strong feelings. Like the Harlows’ monkeys, they may have an animalistic fight or flight response, either attacking themselves or shutting down altogether (Strong, 1998).
The biochemical changes associated with puberty cause many adolescents, particularly those who were formerly abused, to act out and act in. It is not surprising that body control issues, like cutting and eating disorders, are more common among females, and typically have their onset at adolescence. Lisa Cross wrote:
From birth to death, a female’s experience of her body is far more confused and discontinuous than a male’s: from her partially hidden genitals to the pain and mystery of menstruation to the abrupt and radical changes in body contours and function associated with puberty and childbearing to the symbiotic possession of her body by another life during pregnancy and breast feeding. As a result, some women see their bodies as fragmented, foreign, unfamiliar, frightening, and out of control (Strong, 1998, p. 125).
Cross explains that cutting is a way for these burgeoning women to control their own bodies. Unlike the bleeding of menstruation, blood from cutting is within their control. The developed ability to conceive children results in a distressing change in female perception, as does males’ realization that they can father children (Anderson, 2000). Adolescents are realizing, perhaps for the first time, that they have control over their own mortality, and the ability to create other lives from their own (Evans & Hawton et al., 2005). The discomfort that stems from this realization causes some adolescents to behave in drastic ways.
Adolescents who do not self-harm display healthier communication skills than those who do. Self-harming adolescents are more likely to identify themselves as having serious problems and needing help, but rarely seek any. People with multiple episodes of self-harm said that there were fewer categories of people they could talk to than individuals with single episodes, and even fewer still than adolescents with no self-mutilating behaviors. Teachers and parents rank low in the list of people whom these individuals communicate their problems to, with friends occupying the top of the list. It is unclear whether lack of communication increases one’s risk for self-harm, as people who self-harm become more socially isolated as they become more dependent on their injurious behavior, or whether a third factor, such as the elevated depression and anxiety symptomology associated with self-harm, is connected with both self-harming and social alienation. Adolescents who deliberately-self harm are more likely to stay in their rooms, get angry, and focus more on avoiding their problems than solving them (Evans et al., 2005). This lack of communication ability coincides with that discussed regarding traumatized children who do not know how to adequately express their emotions and have difficulty forming social relationships.
Given the large number of factors associated with self-injury, there are many predictors of such behaviors at an early age. The factors appear to be predominantly environmental rather than innate, as parents’ reports of child psychopathology at age three have had no predictive validity in terms of later acts or ideation of self-harm at age 15. Several factors have been used to predict ideation and action correctly based on self and parent reports at age 12. Female gender, mother’s health problems, living in a non-intact family, self-reports of internalizing problems and somatic complaints, parent reports of child’s externalizing problems, being bullied and aggressive, and having learning difficulties at age 12 independently predicted self-reported acts of self harm three years later. Self-reports of deliberate self harm at age 12 were one of the best predictors of continued self-injury at age 15, as those with one incident of self-mutilation are most likely to repeat such behavior. An increase in acts from 12 to 15 was more common in girls than boys, though the rate of ideation remained constant for both genders. This study into predictors of self-harm demonstrated that 42% of those with self-reported injurious behavior and 32% of those with parent reported self-harm at age 12 actually had ideations or actions at age 15 (Aromaa & Haavisto et al., 2005). Investigating serotonin and opiate imbalances could also be used to narrow down potential self-mutilating individuals. Early detection of the above warning signs is suggested as a preventative measure. The study shows a large lapse in data from age three to age twelve. Future research might indicate that psychologists could find these or other symptoms at an earlier age in order to better identify people who self-harm before they develop the habit.
Marilee Strong wrote that “the study of self-injury makes clear that the mind and body are inextricably linked, each feeding from the other’s nourishment or starving from the other’s neglect” (Strong, 1998, p. 88). Research detailing the retardation of children’s communication and coping mechanisms as a result of inattentive, rejecting, and abusive parents illustrates that this is clearly the case. Alice Miller was correct. One can attempt to repress childhood traumas, but ultimately the body will present its bill in blood and scars.
Andover, M.S., Gibb, B.E., Orrico, E.G., Pepper, C.M., & Ryabchenko, K.A. (2005) Self-mutilation and symptoms of depression, anxiety and borderline personality disorder. Suicide and Life-Threatening Behavior, 35, 581-589.
Anderson, R. (2000). Assessing the risk of self-harm in adolescents: A psychoanalytical perspective. Psychoanalytic Psychotherapy, 14, 9-21.
Aromaa, M, Haavisto, A, Helenius, H, Pihlakoski, L, Rautava, P, Sillanpaa, M, et al. (2005). Early predictors of deliberate self-harm among adolescents. A prospective follow-up study from age 3 to age 15. Journal of Affective Disorders, 93, 87-95.
Evans, E, Hawton, K, & Rodham, K. (2005). In what ways are adolescents who engage in self-harm or experience thoughts of self-harm different in terms of help-seeking, communication and coping strategies?. Journal of Adolescence, 28, 573-586.
Groholt, B. & Hjelmeland, H. (2005). A comparative study of young and adult deliberate self-harm patients. Crisis, 26, 64-71.
Gutierrez, P.M., & Muehlenkamp, J.J. (2004) An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide and Life-Threatening Behavior, 34, 12-21.
Lowenstein, L.F. (2005).Youths who intentionally practise self-harm. A review of the recent research 2001-2004. International Journal of Adolescent Medicine and Health, 17, 225-230.
Nock, M.K., & Prinstein, M.J. (2005). Contextual features and behavioral functions of self-mutilation among adolescents. Journal of Abnormal Psychology, 114, 140-145.
Skegg, K. (2005).Self-harm. Lance, 366, 1471-1479.
Strong, M. (1998) A Bright Red Scream: Self-mutilation and the language of pain. New York: Penguin Books.
If you have not yet read Isaiah Vianese’s guest post on Writing, Reading, and Healing, you can check it out here. You might also enjoy a list of quotes related to writing, reading, and healing here. Stay tuned this week for a review of Cheryl Rainfield’s Scars, a guest post, and a giveaway. If you would like to share any of your own thoughts or stories related to writing, reading, and healing, please contact me here.