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May 23, 2012

Why do people deliberately injure themselves?

Drowning in the dark blood of would-be brothers who,
beyond the pressing of fingers, those for whom
the slice is only the beginning, and a different kind
of light comes in, begs recognition and peace of mind.
-- Judybats

This may be the aspect of self-harm that is most puzzling to those who do not do it. Why would anyone choose to inflict physical damage on him or herself? Because they cannot imagine themselves doing such a thing under any circumstances, many people dismiss self-injury as "senseless" or "irrational" behavior. And certainly it does seem that way at first glance.


But people generally do things for reasons that make sense to them. The reasons may not be apparent or may not fit into our frame of reference, but they exist and recognizing their existence is crucial to understanding self-harm. With understanding of the reasons behind a particular act of self-harm comes knowledge of the coping skills that are lacking. When you know what skills are missing, you can start trying to introduce them.

This page is in two sections. The first has to do with what people who engage in SIB say it does for them. The second deals with possible biological or psychoneurological reasons -- why some people find relief in self-harm while others don't. The message of both is simple: It's about coping.

The assumption is that the alternative to self-injury is "acting normally," but on the contrary . . . the alternative to self-injury is total loss of control and possibly suicide. It becomes a forced choice from among limited options.
Solomon and Farrand (1996)

Psychological motivations:

What self-injurers say SI does for them

Many papers on self-harm (Miller, 1994; Favazza 1986, 1996; Connors, 1996a, 2000; Solomon & Farrand, 1996; Ousch et al., 1999; Suyemoto, 1998; and others), have uncovered possible motivations for self-injurious behavior:
  • Escape from emptiness, depression, and feelings of unreality.
  • Easing tension.
  • Providing relief: when intense feelings build, self-injurers are overwhelmed and unable to cope. By causing pain, they reduce the level of emotional and physiological arousal to a bearable one.
  • Relieving anger: many self-injurers have enormous amounts of rage within. Afraid to express it outwardly, they injure themselves as a way of venting these feelings.
  • Escaping numbness: many of those who self-injure say they do it in order to feel something, to know that they're still alive.
  • Grounding in reality, as a way of dealing with feelings of depersonalization and dissociation
  • Maintaining a sense of security or feeling of uniqueness
  • Obtaining a feeling of euphoria
  • Preventing suicide
  • Expressing emotional pain they feel they cannot bear
  • Obtaining or maintaining influence over the behavior of others
  • Communicating to others the extent of their inner turmoil
  • Communicating a need for support
  • Expressing or repressing sexuality
  • Expressing or coping with feelings of alienation
  • Validating their emotional pain -- the wounds can serve as evidence that those feelings are real
  • Continuing abusive patterns: self-injurers tend to have been abused as children.
  • Punishing oneself for being "bad"
  • Obtaining biochemical relief: there is some thought that adults who were repeatedly traumatized as children have a hard time returning to a "normal" baseline level of arousal and are, in some sense, addicted to crisis behavior. Self-harm can perpetuate this kind of crisis state
  • Diverting attention (inner or outer) from issues that are too painful to examine
  • Exerting a sense of control over one's body
  • Preventing something worse from happening
These reasons can be broadly grouped into three categories:

Affect regulation -- Trying to bring the body back to equilibrium in the face of turbulent or unsettling feelings. This includes reconnection with the body after a dissociative episode, calming of the body in times of high emotional and physiological arousal, validating the inner pain with an outer expression, and avoiding suicide because of unbearable feelings. In many ways, as Sutton says, self-harm is a "gift of survival." It can be the most integrative and self-preserving choice from a very limited field of options.

Communication -- Some people use self-harm as a way to express things they cannot speak. When the communication is directed at others, the SIB is often seen as manipulative. However, manipulation is usually an indirect attempt to get a need met; if a person learns that direct requests will be listened to and addressed the need for indirect attempts to influence behavior decreases. Thus, understanding what an act of self-harm is trying to communicate can be crucial to dealing with it in an effective and constructive way.

Control/punishment -- This category includes trauma reenactment, bargaining and magical thinking (if I hurt myself, then the bad thing I am fearing will be prevented), protecting other people, and self-control. Self-control overlaps somewhat with affect regulation; in fact, most of the reasons for self-harm listed above have an element of affect control in them.

In an interesting theory that combines all three categories, Miller (1994) posits an explanation for why such a large majority of peep who self-harm are female. Women are not socialized to express violence externally and when confronted with the vast rage many self-injurers feel, women tend to vent on themselves. She quotes the feminist poet Adrienne Rich:

"Most women have not even been able to touch
this anger except to drive it inward like a
rusted nail."

Miller says, "Men act out. Women act out by acting in." Another reason fewer men self-injure may be that men are socialized in a way that makes repressing feelings the norm. Linehan's (1993a) theory that self-harm results in part from chronic invalidation, from always being told that your feelings are bad or wrong or inappropriate, could explain the gender disparity in self-injury; men are generally brought up to hold emotion in.

Alexithymia

Alexithymia is a fairly recent psychological construct describing the state of not being able to describe the emotions one is feeling. Alexithymia was positively linked to self-injurious behavior in a 1996 study (Zlotnick, et el.) and is congruent with how people who self-injure often describe the emotional state before an injury; they frequently cannot pinpoint any particular feeling that was present. This is especially important in understanding the communicative function of self-injury: "Rather than use words to express feelings, an alexithymic's communication is an act aimed at making others feel [those same feelings]" (Zlotnick et al., 1996).

Self-capacities and Invalidation

A constructivist theory of self-injurious behavior (Deiter, Nicholls, & Pearlman, 2000) holds that people who self-injure usually have not developed three important self-capacities: the ability to tolerate strong affect, the ability to maintain a sense of self-worth, and the ability to maintain a sense of connection to others. The first of these speaks directly to the affect-regulation role of self-harm; the others are perhaps related to its communicative functions.

Pearlman et al. (2000) note that "when children experience shaming and punitive rhetoric or physical blows rather than responsive words" they cannot internalize others are loving and cannot develop the capacity to maintain a sense of connection to others. They further state, "The ability to experience, tolerate, and integrate strong affect cannot develop fully when strong feelings are met with punishment or derision." Having a sense that some feelings are unacceptable and not allowed also impairs this ability. And the ability to maintain a sense of oneself as a person of worth cannot be developed when a child never feels she is good enough, when her "existence and accomplishments are met with silence or abusive words or actions."

Interestingly, all of these conditions are found in invalidating environments, which Linehan and others have tied to future self-injury.

Finally, Haines and Williams (1997) found that self-mutilators reported more use of problem avoidance as a coping strategy and perceived themselves to have less control over problem-solving options. This feeling of disempowerment may in turn be related to the chronic invalidation many self-injurers have experienced.

Physiological concerns: What the researchers have found

People who self-injure tend to be dysphoric -- experiencing a depressed mood with a high degree of irritability and sensitivity to rejection and some underlying tension -- even when not actively hurting themselves. The pattern found by Herpertz (1995) indicates that something, usually some sort of interpersonal stressor, increases the level of dysphoria and tension to an unbearable degree. The painful feelings become overwhelming: it's as if the usual underlying uncomfortable affect is escalated to a critical maximum point. "SIB has the function of bringing about a transient relief from these [high levels of irritability and sensitivity to rejection]," Herpertz said. This conclusion is supported by the work of Haines and her colleagues.

In a fascinating study, Haines et al. (1995) led groups of self-injuring and non-self-injuring subjects through guided imagery sessions. Each subject experienced the same four scenarios in random order: a scene in which aggression was imagined, a neutral scene, a scene of accidental injury, and one in which self-injury was imagined. The scripts had four stages: scene-setting, approach, incident, and consequence. During the guided imagery sessions, physiological arousal and subjective arousal were measured.

The results were striking. Subject reactions across groups didn't differ on the aggression, accident, and neutral scripts. In the self-injury script, though, the control groups went to a high level of arousal and stayed there throughout the script, in spite of relaxation instructions contained in the "consequences" stage. In contrast, self-injurers experienced increased arousal through the scene-setting and approach stages, until the the decision to self-injure was made. Their tension then dropped, dropping even more at the incident stage and remaining low.

These results provide strong evidence that self-injury provides a quick, effective release of physiological tension, which would include the physiological arousal brought on by negative or overwhelming psychological states. As Haines et al. say

Self-mutilators often are unable to provide explanations for their own self-mutilative behavior. . . . Participants reported continued negative feelings despite reduced psychophysiological arousal. This result suggests that it is the alteration of psychophysiological arousal that may operate to reinforce and maintain the behavior, not the psychological response. (1995, p. 481)

In other words, self-injury may be a preferred coping mechanism because it quickly and dramatically calms the body, even though people who self-injure may have very negative feelings after an episode. They feel bad, but the overwhelming psychophysiological pressure and tension is gone. Herpertz et al. (1995) explain this:

We may surmise that self-mutilators usually disapprove of aggressive feelings and impulses. If they fail to suppress these, our findings indicate that they direct them inwardly. . . . This is in agreement with patients' reports, where they often regard their self-mutilative acts as ways of relieving intolerable tension resulting from interpersonal stressors. (p. 70).

A recent case study (Sachsse et al., 2002) supports the idea that self-injury acts to reduce physiological and thus emotional stress. They tracked the nightly cortisol levels in a woman who self-harmed, then compared the results for days on which she did not engage in self-harm acts to those for days during which she did hurt herself. Cortisol excretion is increased under stress, which makes it an excellent marker for stress levels. An analysis of the results showed that on the days during which the woman had harmed herself, her cortisol levels were significantly lower than on other days.

Another stress-reduction theory, set forth by Herman (1992), says that most children who are abused discover that a serious jolt to the body, like that produced by self-injury, can make intolerable feelings go away temporarily. This may help explain how self-injury gets entrenched as a coping mechanism.

Brain chemistry and serotonin

Brain chemistry may play a role in determining who self-injures and who doesn't. Simeon et al. (1992) found that people who self-injure tend to be extremely angry, impulsive, anxious, and aggressive, and presented evidence that some of these traits may be linked to deficits in the brain's serotonin system. Favazza (1993) refers to this study and to work by Coccaro on irritability to posit that perhaps irritable people with relatively normal serotonin function express their irritation outwardly, by screaming or throwing things; people with low serotonin function turn the irritability inward by self-damaging or suicidal acts.

Zweig-Frank et al. (1994) also suggest that degree of self-injury is related to serotonin dysfunction. More recently, Steiger et al. (2000), in a study of bulimics, found that serotonin function in bulimic women was significantly lower in bulimics who also engaged in self-harm. More information on the likely role of serotonin in self-injury can be found on the psychopharmacology page.

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