Self-Injury: A Growing Epidemic Problem
by K. R. Juzwin, Psy.D.
There is a growing awareness of people who engage in self-injurious behaviors (SIB), although it is not a new problem. Recently, self-injury as a pattern of behavior in children and teens is receiving more attention. People are recognizing it, talking about it and seeking help for this problem, and it is gathering more attention in the media. The focus of this brief article is to provide general information about this problem related to teenagers. Also, to help people recognize what the problem is, and to help explain what the course of treatment and management involves. This article is designed to briefly introduce important concepts about the problems involving self-injury, but is not designed to take the place of treatment or answer specific case related questions.
General Information about Teens and Self-Injury
The term "self-injury" refers to a number of behaviors that involve intentional self-directed and self-inflicted harm to one's body. When we look for the reason to explain why anybody would engage in this behavior, it is hard to understand initially. It is not a behavior that occurs alone, there is almost always some other larger problem or problems the individual is dealing with as well. Those problems range from social and age appropriate developmental problems to serious psychiatric problems. It is not uncommon to see a cluster of other problems present as well. It isn't often though, that people make the connection between the behaviors and problems until the connection is pointed out in therapy.
It appears that cutting is the most frequently reported self-injurious behavior. There are a variety of types of injury that people engage in, including; burning, skin picking, pinching, abrasion of skin to injecting compounds, ingestion of nonfood items, breaking bones, and drawing blood. These injuries can range from very superficial to very serious and potentially life-threatening. Self-injury can be impulsive, occurring almost without thought or observable provocation. It can also be ritualized and prolonged. Sometimes people will dissociate, or lose conscious contact with the present ("check out") when they are engaging in this behavior. Patterns of self-injury tend to be specific to the individual, as are the specific body locations where each individual tends to injure. The most common area tends to be on the forearm. Other locations can be on the thigh, calves, or around the ankles. As these areas may or may not be covered by clothing it may not be possible to see them. Other times people will injure on inner thighs, abdomen or breasts. Most times, self-injurious behaviors are private solitary activities. However, there is an increase in groups of teens gathering to engage in "cutting clubs."
Self-injury is not a new problem for clinicians who treat people seeking help for emotional health related problems. In a treatment setting, this problem is generally seen as one part of a larger group of problems. For example, it is not uncommon to see an individual with problems related to depression, eating disorders, anxiety related problems, substance abuse, and/or trauma backgrounds, who also present with self-injury. Often, these individuals will rotate through various types and severity of symptom presentation. This means that sometimes they experience serious depression and substance abuse problems, and then at others, body image or eating disordered related problems. Other problems can include anxiety, school phobia or refusal.
At the far extreme, some individuals experience psychosis, or lack of contact with reality intermittently as part of the entire cluster of symptoms they experience. In the hospital setting, both inpatient and outpatient day treatment settings, self-injury has become a primary reason for referral to the hospital or therapist for treatment. It is important to note that self-injury, while being the reason many people will seek treatment, is never a problem that happens without other problems being present as well. So it is not uncommon that people seek treatment for any number of problems. Once self-injury is discovered, it should never be minimized as the seriousness needs to be assessed.
Further, when this problem is identified to happen in a school setting, most schools see this as an urgent problem. Part of this problem is because of their concern over someone engaging in self-destructive behavior that could be dangerous. Another concern is the contagion effect, which is an effect that just by awareness of something, it becomes more prevalent. Kids teach each other things, good and bad. Most kids upon hearing about this behavior will be less than enthusiastic about it, but for others, it will become something to consider as an outlet. It appears to be following the same patterns as the spread of eating disorders, atypical dieting, sexual experimentation and substance abuse. And, for some of these kids, it becomes a forum for cohesion, where kids are now forming "cutting clubs" that may or may not have a plan for at least one suicide.
Self-injury and Suicide
Self-injury serves a purpose that is difficult to understand. The one reported most frequently by our individuals is that it is a way to stay alive, to cope, to manage or to relieve stress or tension. Other reasons include to numb down, to quiet down, to control, or to "check out." Some people use it to punish themselves before someone else does, as in the case of abuse. Self-injury for many of our individuals has become a habitual way to manage.
It is important to recognize that self-injurious behavior or thinking is different than the thinking that is associated with a suicidal act, where the intention is to escape or die. Self-injury is used as a way to stay alive and manage staying alive and the demands that go with that life. That's not to say that many of our individuals aren't also at risk for suicide, it's just a different part of the problem. However, many of these individuals will report that they often "feel suicidal." It is important to recognize that these individual's are feeling overwhelmed, lack a language to talk about their internal experience and are maxed out related to their ability to manage.
Sometimes families feel overwhelmed with the demands of children who are at this extreme. Sometimes they feel manipulated and frustrated by these patterns. No matter what happens, these statements are never "just for attention." Besides, it is healthy, developmentally appropriate and necessary to give our kids attention.
Defining Who and Why
The problem of self-injury is not confined to any one demographic, ethnic or socioeconomic group. Although women/girls seek treatment more frequently and for different problems than do men/boys, self-injury appears to not be selective with who engages in it. In treatment settings, we tend to see more teenage girls than boys seeking treatment for primary self-injury. Many of our males though, tend to be in treatment because of behavior disorder related or substance abuse problems. Both sexes tend to use cutting as the most frequent form of self-injury, followed by burning or scratching. We have seen that many of our individuals began harming themselves when they were as young as eight or nine, but often did not receive treatment until they were 13 or older. It is important to note that a history of trauma (significant loss, physical, sexual, emotional abuse) is seen in a portion of these individuals, but not all. Additionally, it is important to understand what the individual perceives as significant, not just impose a judgment.
Self-injury may lessen and worsen depending on the particular struggle the individual is having with overall managing daily life and the problems in it. When someone is using self-injurious behavior to manage, it is important to see this as a sign that the person has maxed out their capacity to manage and cope in healthier ways. Sometimes people don't possess the vocabulary or conceptual abilities to be able to talk about their experiences.
The cluster of problems we see break down roughly into several different patterns. One cluster of problems includes anxiety and school phobia, where the self-injury serves to help manage to escape the anxiety. Often self-injurious behavior helps the individual get out of situations that frighten them, like school. Helping these children get back into school is an especially difficult experience with these children, families and schools.
Another cluster is the over-achieving kid, the "perfect" or "all around great" kid by outward standards. Often, as this façade becomes exposed, we have a great kid who has such extraordinary standards placed on them by themselves and by others. These kids often fall apart silently and in private. Parents of these kids are often surprised to learn their kids have problems because they appear so together and capable of managing everything. The difficult thing is that these kids work hard on never disappointing or displeasing anybody or anything. There may also be problems with anxiety, substance abuse, eating disorders, and sexual promiscuity, as well as self-injury. Their families often struggle with getting their kid back to "normal," when in reality the drive for "normal" was equated with being perfect, and was part of the problem. Often these kids have responsibilities and privileges beyond what is age appropriate.
One group of teens that we also see referred from schools, are those kids who have serious behavioral problems, where self-injury is one way they manage their anger, frustration and confusion. Often these kids have trouble fitting in, disregard rules and authority. It is not uncommon to see that they have little support outside of the hospital, both at school and within their families. They may have problems with the law. They may identify themselves with very negative peer groups.
We have seen teens that come into for treatment presenting with self-injury who are also at a point where they are beginning to decompensate into a very serious mental health problem. The self-injury may be sporadic, but serious. Substance abuse may or may not be seen in this situation. When physicians ask about history of mental illness, it is partly because many of these serious disorders have a genetic or biological component, and relating that information to your doctor becomes extremely important in helping to manage the illness early on.
Many of our kids have come from backgrounds that have been chaotic, abusive or traumatic. It is important to note that not all children from abusive backgrounds injure themselves. Many of our kids come from homes where parents did not parent with regards to what the child needed at each phase of his or her development. That may be a very unpopular statement. Most parents genuinely work hard at raising their kids the best they can. And, parenting is certainly not easy. Unfortunately many family patterns or household patterns end up being harmful to those in it, especially for the children who grow up in them. Many parents are unaware of how they family dynamics or patterns affect the people living in them. Remember, children are great observers, but lousy interpreters, so one is never certain of the sense they make of things. Most often though, children blame themselves for the "bad" things, and don't hold people accountable or responsible because they aren't in a position to do so. Don't underestimate the role that family and society has in contributing to the development and maintenance of these problems and as well as in the recovery process.
Early trauma, stress, or chaos in a child's life changes their brain development and physiology related to interacting with the world. Self-injury and atypical eating become two ways of managing the internal intensity these individuals experience.
Social and Family Contributions
The commonality all of these individuals is that they are developing human beings. When you look at the developmental demands of adolescence, there is an emphasis on developing a sense of who you are in relation to your peers and society, but generally against your family of origin. Few people feel like they fit in anywhere during this time. Groups form around common ideas, values, feelings, or attitudes. The group allows one to fit in. We also know that brain and physiological changes are occurring, especially in the part of the brain that drives emotional regulation. So when we say our teens "don't think rationally" at times that may be true. Add to that a very limited experience reference base, poor frustration tolerance and desire for immediate gratification and it's quite a lot to manage.
Generalized social standards, dictated through magazines, movies, television, advertisements and music, are aimed at generating income for those who produce them. Unfortunately, our reactions tend to not see this as consumer options being presented to us which we could accept or discard. Often these blitz of images comes to define what is right, wrong, in or out, and what we should strive to be. Our generalized society has an adolescent mentality, and many of us as adults have bought into it as well. While this may seem to be an interesting and controversial statement to make in the scope of this article, it serves a purpose. People who have internal ways of tolerating self-definition, self-management, and frustration tolerance in healthy ways, tend to not to be so dependent on these perceived external demands.
When people have reasonable and consistent standards and limits, with reasonable consequences and rewards that are age and developmentally appropriate things are different. They may argue with their parents, which is age appropriate. Parents need to tolerate their kids' frustration, and help them learn to live with disappointment, frustration and delay of gratification. Parents who help their kids learn to problem solve, help their kids move away from self-destructive options. What is needed is that parents have the expectations that the kid will behave in healthy and nondestructive ways. Parents also need to realize that their children need them to place limits and expectations on them and hold them accountable to those. Further, parents need to set the same expectations for their kids related to being healthy and accountable. Privileges are earned, not given. Responsibilities must be age and developmentally appropriate. The kid should have something to work towards attaining. The family needs to function with adult and child roles.
Conclusion
Self-injury is both a trend behavior and a problematic symptom of a larger picture. If you know someone who is engaging in this behavior, please direct the individual to the appropriate health care provider. Don't minimize the problem, or let them. When someone is using this behavior, it is serious. If you are a parent, this is an opportunity to help your child manage something bigger than they can manage alone.
Download the following book excerpts from K.R. Juzwin, Psy.D for more practical help dealing with the issue of self-injury:
A Lesson about Self-Injury Behaviors & Thinking: Important Facts
A Guide to Help Those Who Love Someone Who Self-Injures: Family Patterns
A Guide to Help Those Who Love Someone Who Self-Injures: Investment in the Family Unit
K.R. Juzwin is the Director of Self-Injury Recovery Services, SIRS Program, Alexian Brothers Behavioral
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