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Definition
Self-injury is best defined as the deliberate mutilation of the body or a body part, done not with the intent to commit suicide but as a way of managing emotions that seem too painful for words to express. It can include cutting or burning the skin or bruising oneself through a premeditated accident. It can mean scratching the skin until it bleeds or interfering with the healing of wounds. In more extreme cases, self-injurers break their own bones, swallow harmful substances or inject toxins into their bodies.
Self-injury encompasses a range of behaviors, some of them not so distant from the stress-busting strategies of the healthy population. There are people who bite their nails, pick at blemishes, scratch mosquito bites until they bleed or even get bad sunburns in spite of all of the warnings of sun damage. However, these behaviors do not approach the line between the harmless things that people do to their bodies and those that warrant serious attention.
History of Self-Injury
Though the media and the medical community appear to have just discovered self-injury, the phenomenon was documented as early as biblical times. Mark 5:5 refers to a demon-possessed man who "always, night and day, was crying and cutting himself with stones." In the Middle Ages a religious sect known as the "flagellants" wandered through Europe, lashing themselves with cat-o'-nine-tails, attempting to atone for society's sins and to lift the great plague ravaging the continent. Manifestations of self-injury — as ritual, rite of passage or to appease angry gods — have existed in virtually every culture and every era.
Motivations for Self-Injurious Behavior
The purposes of self-injury fall under two broad headings:
- Analgesic or palliative aims
- Communicative aims
Analgesic aims
The self-injurer experiences pain and distress as never ending. Feeling anxious or agitated can quickly escalate into panic, accompanied by the physical sensations of a severe anxiety attack. Strangely, self-injuring behavior provides relief from these distressing symptoms. The disturbed person may look on such behavior as a sense of turning to a completely safe and reliable best friend, one that has never shown disappointment or threatened abandonment. Research by van der Kolk (1989) suggests that when the self-injurer harms herself, the brain releases chemicals that function as relaxants, producing a calming, soothing sensation. The tension and agitation drains out, so the person feels she can control her thoughts and feelings once again.
Another palliative effect of the behavior is in the connection of body and mind. Self-injurers usually suffer from faulty connections between physical and emotional selves. For patients who feel distanced from reality, isolated or dehumanized, the sight of their own blood can jolt them back to reality. It reassures them that they are alive, intact and have personal boundaries.
Cutting also serves another fantasized purpose, that of cleansing or purifying. A sense of being inherently bad or dirty may have been conveyed to some people as children, leading the self-injurer to hold this opinion of her body and sexual self.
Communicative Aims
Self-injurers usually have difficulties identifying and communicating emotional states, wishes and needs. For instance, they might hang their hat on one emotion — like anger — and use it to describe almost any state of being "worked up."
Most self-injurers grew up feeling neglected, unheard and misunderstood, leading to hopelessness about the prospects of using words to get one's needs met. In fact, they believe that their harmful acts show, in a way that language cannot, how much pain they're suffering. This is a response usually associated with young children who lack the facility to behave differently, and it often leads to immediate action. Most self-injurers have not advanced beyond this regressed way of communicating feelings to others. A former self-injurer describes the behavior as a communication tool, "the tangible face to my intangible pain — see my pain!"
All of the following are motivators for self-injurious behavior:
- Limited or primitive communication
- Need for attention
- Punishment of self/others
- Control over affect states
- Avoidance of separation/loss
- Control over relationships
- Self-preservation
- Suicide prevention
Prevalence
Just as national preoccupation with thinness and fitness appeared to give rise to anorexia and bulimia over the last two decades, so have a complex mélange of cultural and social factors helped bring on the rising tide of self-injury. The syndrome has taken the 1990s by storm; its grip on schools, college campuses, jails and other sectors of society continues to tighten.
The phenomenon is not selective of social strata. In Hollywood, celebrities like Roseanne and Johnny Depp have said in interviews that they have struggled with the problem. Even Princess Diana of Wales, before her premature death, said in a television interview that she had cut herself deliberately several times. A new biographer of Alfred Kinsey, the sex researcher, reveals that he too engaged in self-injurious activities, including an attempt to circumcise himself.
How did such a seemingly curious behavior grow so quickly over such a short period of time? One could speculate that contagion must have played some role. Media exposure of the problem — while efficient in getting self-injurers the care they need — may also inadvertently give people new ideas. Music groups now express themes of self-injury, and even popular television shows like Beverly Hills 90210 and Seventh Heaven give exposure to the problem.
More significantly, people, particularly teens, who are desperate to fit in with their contemporaries, tend to take their cues from one another. We must add, however, that it is not the typical, well-adjusted adolescent or adult who is likely to run with the role model of self-harm. Rather, it is the psychologically vulnerable person who may seize on something she views as a fad and fashion it into a strategy to deal with preexisting agonies.
Adolescent Incidence
Being tough and rebellious are hallmarks of adolescence, when youths latch on to cultural trends they think will annoy their stodgy parents. The 1960s and 1970s had the rumpled "hippie" look, which seemed threatening at the time, but in retrospect seems to have conveyed a benign message of peace and harmony. Heavy drug use was the down side. The 1980s featured a number of different looks, notably the sexed-up paradigms of the Valley Girl and the Material Girl. While those ideals appalled traditionalists by emphasizing the sex appeal of young girls, the trends did place value on taking care of one's body and appearance.
The 1990s have brought grunge. Some hypothesize that self-injury has taken such a hold among teenagers because of the disheveled look: super-baggy pants, ripped T-shirts, messy hair, tattooed and pierced skin that seems to tell the world, "I don't feel good about myself." When teenagers cultivate this look and attitude, it seems less of a stretch for them to begin injuring themselves. Some self-injuring teenagers carve words into their bodies using disparaging and vulgar remarks about themselves, fat and ugly being the most common.
The task of the adolescent is to leave childhood and begin forging an independent, adult identity. Rites of passage help to define the process and guide the metamorphosis. However, as the number of structured rites of passage observed by society dwindle, some teens are filling the void with self-injury. Therefore, the behavior becomes a token of independence and a symbol of separation.
Adolescents and young adults who are struggling with issues of self esteem may become more frenzied in their attempts to communicate with their parents with more and more visibly self-damaging behavior. Some graduate from eating disorders to self-injury, angry and defiant gestures with the twin goals of gaining a response from adults and pushing people away. Behaviors considered outrageous by the adult world ten years ago don't even produce a blink anymore, pushing the "acting out" adolescent toward increasingly horrific behaviors. Many adult self-injurers have similar feelings about the people in their lives, and the lengths to which they must go to capture the interest of others.
Adult Women
Like the spate of housewives in the 1950s who became alcoholics to escape the boredom of being stay-at-home moms in suburbia, some of today's women are turning to self-injury to cope with the mass of pressures facing them.
First, they try to fulfill the myth of Superwoman, a woman who does everything, from working and earning money to tending house and kids. Study after study shows that even after hundreds of millions of women have entered the workplace, men are not picking up the slack in household tasks. By and large, the "privilege" of working has simply added to a woman's burden rather than replacing one set of tasks with another. Moreover, the working woman's psychic grievances are exacerbated by the string of cutely labeled workplace phenomena that hold her back: the "Mommy Track" and the "Glass Ceiling."
Despite the progress made by women's liberation and other forces, anything female is still denigrated as "less than" male. Women are still expected to be responsible for the brunt of domestic duties and are belittled if they cannot do that as well as hold a job. Men don't question this arrangement, since child rearing in our culture is seen as women's work, an easy task with low importance. This attitude may be showing itself in the increase in self-destructive behaviors among our children — and among older women, whose voices are stifled even as more is expected of them.
Cultural Forces
S.A.F.E. Alternatives, one unique treatment program for this disorder, has identified the following contributing phenomena to self-injury.
Society is becoming increasingly disenfranchised. The extended community of grandparents, aunts, uncles and neighbors is seldom available for day-to-day support or to help parents care for children. This is especially true among Caucasians, from which the statistical preponderance of self-injurers emanate.
The collapse of the extended family and increasing isolation of the individual has given people, especially children, fewer confidants in times of difficulty. The modern child may grow up relying very little on words, verbal expression and the conversational exploration of thoughts and feelings. Technology has exacerbated this tendency, sending us all around on our own in our personal, motorized driving-pods or sitting by ourselves in front of our private liquid-crystal-display computer screens.
Our culture increasingly emphasizes the "quick fix," immediate gratification. Even fast-food meals are too slow, and television commercials are too long for us. By extension, any feeling that is experienced as uncomfortable must be attended to instantly, given voice through some sort of action or behavior that offers immediate, palpable relief.
We have become a nation of addicts. Sexual perversions, kleptomania, incest, compulsive shopping, gambling and self-injury are all statistically on the rise in the last two decades. Anyone who watches daytime talk shows might well believe that it has become chic to be considered "dysfunctional" in some way — a word that was scarcely on our radar screens a decade ago.
We live in a relentlessly body-focused culture where appearance and presentation are all important, where we are encouraged by cultural imperatives to remain "on the surface of things." The media saturates us with messages about how we can "feel better about ourselves" by modifying the shape, contours or appearances of our bodies. Society beckons all to jump on the bandwagon of diet, exercise, cosmetic surgery, change of hair and skin color in addition to use of a bewildering array of lotions, creams and ointments to heighten beauty.
Persistent and debilitating gender biases are driving young women to more severe emotional extremes than ever before. Self-injury is just one example of the measures girls will take to express their frustration, fear and anger. Mary Pipher (1994) makes this point in her popular bestseller, Reviving Ophelia, blaming the predicament on our "girl-harming" culture.
As more parents work outside the home, latchkey children, having outgrown day care, baby-sitters and nannies, become the norm. More often children are being reared by veritable strangers rather than family members, and as they approach adolescence, children are literally rearing themselves, looking toward their peers for guidance.
The Significance of Breaking Skin
As long as human beings have existed, they have used the skin to communicate identity and status. Cultures both primitive and modern have used tribal markings to unite their community and imbue a sense of belonging. For instance, Native American tribes developed elaborate rituals of facial decoration, markings and cuttings: Hindu women denote their faith with a red dot on the forehead; various African people are known for their distinctive tattooing, scarification and face-painting practices.
This phenomenon is at work today in the United States, where gang members in inner cities boast their affiliation through tattoos, distinctive clothing, body piercings and other cosmetic means. This culture has spread to the mainstream, with middle-class suburban children trying to emulate the hip look of the ghetto.
Among other segments of society, body art-tattoos or piercings can advertise anything from one's political leanings to one's sexual orientation, much the way a bumper sticker does on a car. Self-injuring people often say their scars tell their life's history; each scar represents a particularly important life event that the person does not want to forget. One described it to a reporter for the New York Times, (Egan, 1997) "I've got physical scars — it shows that my life isn't easy. I can look at different scars and think, "Yeah, I know what happened," so it tells a story. I'm afraid of their fading."
Self-injury may be one of our society's fastest growing and most disturbing epidemics. Some experts (Favazza and Conterio, 1988) estimate that more than three million Americans are afflicted with this syndrome. Because of society's reaction to it, self-abuse is a widely misunderstood and dangerously mistreated psychiatric disorder. One innovative treatment program is described in the book Bodily Harm written by Karen Conterio and Wendy Lader, Ph.D. The book describes their S.A.F.E Alternatives (Self Abuse Finally Ends) program that is based on years of clinical experience and research.
Mary Jo Jacobs has a Master's Degree in Nursing from Rush University School of Nursing. Ms. Jacobs has worked as a psychiatric nurse for 25 years and has specialized in personality and eating disorders. She has also worked in community health nursing both with psychiatric patients and the terminally ill. She is currently working as a nurse consultant at the S.A.F.E. Alternatives Program at MacNeal Hospital in Berwyn, Illinois. For information regarding the S.A.F.E. Alternatives Program, please call
1-800-DONTCUT or visit their website at: www.safe-alternatives.com.
References
Conterio, K. & Lader, W. Bodily Harm. New York, Hyperion, (1998).
Favazza, Armando. Bodies Under Siege. 2nd ed Baltimore: Johns Hopkins
Press, (1996).
Bleiberg, E. "Adolescence, sense of self, and narcissistic vulnerability." Bulletin of the Menninger Clinic, vol. 52, pgs. 211-228, (1988).
van der Kolk, B.A. Psychological Trauma. Washington, D.C.: American Psychiatric Press, (1989).
Pipher, M. Reviving Ophelia: Saving the Selves of Adolescent Girls. New York: Ballantine, (1994).
Egan, J. "Cutting." New York Times Magazine, (July 27, 1997).
Favazza, A. & Conterio, K. "Female habitual self-mutilators." Acta Psychiatricia Scandinavia, vol. 79, (3), pgs. 283-289, (1988).
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