who began cutting herself six months ago, concretely explains the reasons behind this behavior. She says, “Cutting became my cry for help when words could not do it for me. I wanted people to see how ugly I was, and how ugly I felt. I was tired of trying to explain how much I hurt on the inside. I wanted it to show it on the outside.” Rebecca is experiencing great sadness. She is looking for a way to prove to others and to herself that her pain is real. She has difficulty expressing her pain (sadness) verbally, so she chooses to express it physically.
Stephanie illustrates this point as well. However, Stephanie is experiencing tremendous anger. She just turned eighteen and states, “I cannot believe I am now officially an adult. Not much has changed. Certainly not the way I feel about myself. Hate is a powerful feeling. It rises within me, there is no ceiling. I mark myself to show my pain. I do not yell and I never scream. I hold it all in and let it consume me. Then the pain comes. It flows through me - slow, smooth, gradual - always consuming. This feeling is much more tolerable than hate.”
There are many reasons individuals self-injure, which we will discuss at great length later in this book. The two examples above give a small glimpse of how different emotions can lead to the addictive process of self-injury. Individuals use self-injurious behavior as a way to cope with their distressing emotions. The one common denominator is typically the individual’s difficulty with verbal self-expression. Without this ability, the person is left with a physical means of communication.
Who Self-Injures?
Although study estimates vary, it is generally believed that 13% to 25% of adolescents and young adults surveyed in schools have some history of self-injury. (Rodham & Hawton, 2009). While many of these individuals self-injure only once or twice and then stop, others begin to practice the behavior regularly. Studies of college populations have determined that roughly 6% of college students actively and habitually practice self-injury. While it is likely that this same 6% applies to adolescents as a group, middle schools are likely to have a higher percentage of students practicing self-injury, as the behavior most often begins between the ages of 14 and 16. (Whitlock, Eckenrode, et al., 2006; Gollust, Eisenberg, & Golberstein, 2008). However, individuals also begin injuring in childhood and as adults.
People of all age, gender, sexual orientation, and race self-harm. While self-injury is prevalent in both males and females, it is typically more visible among females. (Whitlock, Muehlenkamp, et al., 2009). Additionally, young people identifying as bisexual, or questioning are considered at higher risk than their heterosexual or homosexual peers. (Whitlock, Eckenrode, et al., 2006; Whitlock, Muehlenkamp, et al., 2009). Individuals from a wide variety of geographic, socioeconomic, and cultural backgrounds participate in this deliberate, repetitive, and destructive behavior.
The reasons behind the need to self-injure are complex and often neglected or misunderstood. As a result, the behavior is frequently kept secret, which suggests that the number of reported cases is significantly lower than the number of actual cases in our country. Most individuals do not willingly seek treatment. If they do enter treatment, it is usually because a loved one insists on intervention. The person most likely to enter treatment is from a middle-to-upper-class family, with average-to-high intelligence and low self-esteem.
Nadia fits this description perfectly. She is 17 years old, bright, and from an upper-class family. She did not want to get help for self-harm. Nadia’s parents “forced her into treatment.” She kept it a secret for several years before they discovered cuts on her arm. Nadia was extremely angry when she entered therapy. She believed that her parents were making “a big deal out of nothing,” and had no desire to share her thoughts and feelings with a complete stranger. She acknowledged that she rarely shared her thoughts and feelings even with people she was close to in her life.
However, through the course of treatment, Nadia began to open up. She admitted that she often felt empty inside. In a therapeutic journal assignment, she wrote, “Sometimes I perceive my world in shades of grey, like a black and white TV show. When I don’t see color, when I feel grey, I feel no emotion other than sadness. Yet I don’t feel sad enough to cry. It is a superficial sadness that tenaciously covers my other emotions so that I can’t reach them. When feeling grey, I’m numb to the world around me and I am numb to myself. This is what entices me to cut. I want to see red. I want to see color. I want to feel something.”
It is not uncommon for individuals who self-injure to experience this kind of emptiness, and to use self-harm as a way to experience some sort of feeling. Physical pain helps them to feel alive and not devoid of emotion. Human beings have the ability to feel things deeply. For many individuals who self-harm, seeing blood helps them to feel human.
Many individuals who self-injure report some form of abuse (physical, emotional, or sexual) during their childhood. Van der Kolk, Perry, and Herman (1991) conducted a study of individuals who exhibited cutting behavior. They found that exposure to physical abuse or sexual abuse, physical or emotional neglect, and chaotic family conditions during childhood, latency, and adolescence, were reliable predictors of the amount and the severity of cutting.
Sexual abuse victims were most likely of all to cut. The resulting trauma experienced by the individual can be an underlying cause of self-injurious behavior. This is true for Cathy. She was fifteen and a sophomore in high school when she was brutally raped while on vacation with her family in the Caribbean. Cathy is twenty-two now, and remembers that day as if it were yesterday. Following is one of the poems she wrote to try to make sense of what she was feeling:
Another day, another cut;
pain, release, this island of sanity.
Unreal, decaying, it’s anything but;
weeping, hating, testing morality.
Blood, flowing like a stream; rolling down my arm;
Drifting in a dream; finally feeling so calm.
It’s just another scar; no harm done so far;
Maybe, when I’m pissed; I’ll finally slash my wrists.
Scars upon my body, more upon my heart;
No one in my life; destined to live apart.
My heart aches so bad; it’s literally driving me mad.
Things would be just fine, if only I could see the divine,
I dream the past is gone and a new day will dawn.
Types of Self-Injury
The most common form of self-injury is cutting. There are many objects that individuals use to cut themselves with, including knives, razor blades, and glass. However, individuals who self-injure are not limited to these items. In fact many use instruments that most people would not even think of as something that could cause bodily harm. For example, it is not uncommon for self-injurers to use push pins, paper clips, nail files or staples to inflict injury.
It is also not uncommon for self-injurers to transform a harmless object into a sharp instrument to be used for self-harm. For example, Haley was hospitalized for suicidal ideation last spring. She was known on the hospital ward as a “cutter.” She was placed on suicide watch and almost everything that could cause harm was removed from her room. She was only allowed a marker and paper for journaling. Each day she sharpened the marker’s cap with her teeth, creating a pointed edge she used to cut her arms and legs when she felt the desire. She also gave herself paper cuts with the edges of the paper that was provided to her on a daily basis.
Hillary was Haley’s roommate. She took the hooks that held the curtains in place and used them to scratch her arms and legs before going to bed at night. In addition, she found sharp pieces of metal protruding from one of the legs under a table in the TV room and while still attached, used them to scratch her feet and ankles.
Clearly, if someone is motivated to self-injure they will find a way. The solution is