Self-injury is the deliberate act of physical harm to cause tissue damage. The idea that an adolescent would repeatedly injure themselves does not make sense to parents. In order to deal with self-injuring children a parent needs to understand that self-injury is not entirely senseless or irrational. There is an emotional purpose even though self-injuring behavior is not healthy and certainly does not solve practical problems.
Self-injury is a frequent behavior in about one out of 100 adolescents. Some estimate that as many as seven out of 100 injure themselves. It is far more common in girls than boys. Adolescents who inflict physical self-harm have certain characteristics. These children are very sensitive to rejection even if they may not show it. Their mood is irritable and anxious most of the time. They will look irritable, upset or brooding when they are actually very angry and hostile. Parents need to keep in mind that children who self-injure are trying to hide and control their anger as much as possible. They are usually angrier at themselves than they are at others.
Adolescents who self-injure usually have underlying problems. There is a strong relationship between self-harm and sexual abuse before 13 years of age. That is not the only potential cause. Physical and emotional abuses during early childhood are common experiences among those who self-injure. A traumatic breakup in the family leading to neglect of the child is a common factor. Depression alone is not the cause of self-injury. Depression is closely related to but not the actual cause of this behavior. Self-injuring adolescents may be involved or may become involved in high-risk and dangerous behavior, including alcohol and other drug use. Many of these young people are also bulimic or anorexic.
Motivations for Self-Injury
There are four primary reasons why adolescents self-injure. These can helps parents to understand these motivations. Parents need to set aside the belief that these children are doing this just to manipulate their parents. Adolescents self-injure for reasons most parents would never imagine might make sense.
To Feel Better
Adolescents who self-injure have difficulty coping with their feelings. Their uncomfortable feelings increase and create increasing physical tension and distress. Eventually the childís emotional pain and physical distress become unbearable. When they canít find a healthy way to feel better they allow their feelings to control the moment. Going to sleep is one way they try to feel better. Focusing on activities and distractions is another way to escape the uncomfortable feelings. Escapes and distractions may work for a while. But eventually, for some children, even these are not enough. When a child feels out of control and unable to deal with feelings effectively they may self-injure.
Self-injury is not really about inflicting physical pain as much as it is about escape from emotional pain. The emotional pain and physical tension of an unhappy adolescent can be relentless. By causing physical pain, an adolescent can reduce the level of emotional and physiological distress to a bearable level. Minor physical pain, such as pulling their hair, provides a distraction from their feelings. This can progress to scratching, picking at sores, cutting or burning.
After a while the emotional pain and physical tension of an unhappy adolescent can lead to thoughts of suicide. In some cases, self-injury has an unexpected benefit. Strange as it may sound, self-injury can become a way to prevent and control suicidal tendencies. Self-injury provides a sense of relief and lessens the impulse to commit suicide. It can also provide relief from feelings of guilt, shame and self-hatred.
Some adolescents use self-injury to express something they canít describe or talk about. They may be afraid to communicate or they may not know how to talk about their distress. Parents often misunderstand self-injuring behavior. They tend to see self-injuring behavior as manipulative. This is not the best way to describe this behavior.
An adolescent who shows you their injury is saying, ďI donít know what to say but I want you to see what I did to myself and help me.Ē Self-injury is an indirect attempt to ask for help or to get some need met. Adolescents donít self-injure just to get what they want. They will injure themselves and show you because they think they need something and they canít stand how they feel anymore.
Self-injury is a misguided attempt to communicate and influence the behavior of others. Imagine for a moment how desperate a child must feel when they self-injure and show their parent.
The relief found from self-injury never lasts. The unpleasant emotions and physical distress always return. Children can learn to use their injuries to control and manipulate people after their attempts at communication fail. This childís behavior is saying, ďCutting myself only works for a while to numb the pain. Showing you what I have done hasnít helped. But now that I have got your attention, and since I cut myself anyway, maybe you will act differently.Ē
There are many social, family and personal problems that can build up to the point that a child will begin to self-injure. For example, adolescents may start cutting themselves after their family members are abusive toward each other. Imagine their surprise when cutting themselves makes everybody stop fighting and treating each other badly. The focus of attention shifts to the adolescent instead of individual conflicts.
Self-injury can be reinforced by how it changes the adolescentís world. This is how an adolescent can learn to use self-injuries to control and influence others. An adolescent who self- injures is saying, ďNow that I cut myself, and I now that I have your attention, please give me something that will make me feel better.Ē This may not be a conscious thought. The fact that injury leads to feeling better is enough to make the impulse stronger.
Children may become manipulative unless the parents discover what their child truly needs. Iím not talking about a distraction or allowing them to avoid and escape their feelings. Thatís not a long-term solution. Helping these children discover what they need to find comfort long term, as well as healthy ways to feel better in the near term, is important. Unhappy children need help to find internal, emotional and psychological solutions. They need role models, examples and practice learning to change painful situations. Teaching these skills can be difficult once a child resorts to self-injury. Self-injury can become a powerful compulsion that is difficult to break -- especially when it has seemed to be the easiest, quickest and best solution.
Adolescents can become very angry if they fail in their attempts to communicate and control their feelings, bodies or othersí behavior. They will usually blame themselves, but in some cases they will blame others. They will usually blame themselves first. If that blaming does not satisfy, they blame their parents. They tend to blame their parents or people they are close to when they expect these people to provide for their physical and emotional needs. This process is very similar to that of small children who donít know what they want but feel some kind of pain and donít know how to describe it. These kids get really upset and maybe angry.
Self-injury is one way that an adolescent can punish themselves. Many of these kids were punished as children and they felt far worse because of their punishment than their parents realized. Those who are sensitive and insecure may come to believe they are failures. Self-injury is reinforced when an adolescent believes they should be punished and their self-injury results in emotional relief. An adolescent may punish him- or herself for many reasons.
To avoid or escape from intense unpleasant feelings.
Predicting self-injury is difficult or impossible. We donít know how to tell whether an adolescent will self-injure. There are triggers that increase the risk of self-injury. Unfortunately, the triggers are not obvious and affect each adolescent differently.
A single event alone is usually not enough to cause an adolescent to self-injure. There is usually a build-up. How an adolescent feels about an event or series of events is the important factor. Self-injury is almost always associated with emotional pain and physical distress. Sometimes it is the result of something that happened recently and was connected with painful memories.
People have emotional memories that are not easy to access rationally. Emotional memory helps explain why some adolescents become so overwhelmed and flooded by their feelings. Adolescents can feel something in one moment and that feeling can trigger other feelings. Adolescents can remember and experience feelings without a clear idea what is upsetting them. They may or may not remember the events that caused the emotions. This tide of feelings can grow to a severe level of distress and lead to self-injury. This is how a series of seemingly minor events can cascade to an episode of self-injury.
Guilt and Self-Criticism
Self-injuring adolescents find guilt intolerable. Guilt leads to memories of failure, abandonment, and more feelings of guilt, shame, embarrassment and tension. Adolescents who are self-injuring are usually plagued by guilt. They tend to feel guilty about things that other people would not feel guilty about. This includes their imperfections, awkward social moments and inability to please people.
In almost all cases, self-injuring adolescents are extremely self-critical and spend a lot of time comparing themselves to others. Girls, more so than boys, can become very distressed by their physical appearance. Their standards are usually set too high. Adolescents blame themselves for many things. Ironically, they blame themselves for their own inability to stop blaming themselves.
Failure is in the eye of the beholder. Adolescents can feel the urge to injure themselves as a result of failure. ďFailuresĒ might include disappointing themselves and others. Because they hate failure they will often try very hard to succeed. Their desire to be successful and for others to be successful can be so high that an adolescent can become controlling or difficult to tolerate. An adolescent can lose sight of relationships and assume that everyone feels the way they do about success and opportunities. They can push so hard that others will withdraw from them or confront them.
Some adolescents who self-injure are afraid to try and fail. They avoid failure, but they do want to please people. These kids are more likely to wait until someone gives them direction or tells them what to do. Rather than control others, they may try too hard to please people. But their strategy for success will ultimately fail because they canít please everyone. The moment there is a hint of failure these kids will blame themselves. Harsh language, sarcasm or abuse can send them over the emotional edge.
Failure alone is not the reason adolescents self-injure. How they feel when they fail is the real problem. In most cases one failure reminds an adolescent of other times when they felt like a failure. They may not remember all the events clearly, but they seem to have all the emotional memories of past failures.
Rejection and Abandonment
Feelings of rejection or abandonment are those of sadness and fear. The rejected adolescent feels unimportant. Self-injuring adolescents are very sensitive to any possibility of abandonment or rejection. They want to feel important. A self-injuring child may feel abandoned and rejected when people act unresponsive, awkward, withdrawn or in a bad mood.
Self-injuring adolescents may believe they are being abandoned or rejected when in fact that is not the case. They need a tremendous amount of reassurance. They can be profoundly affected by changes in the behavior of peers, family or friends that they imagine are rejecting them.
The term ďstressĒ refers to a combination of physiological reactions that include muscle tension and unpleasant emotions in response to challenging events or situations. The most common sources of stress are conflicts, failures, changes, situational or interpersonal demands, threats or danger. Stress, regardless of the cause, is an unpleasant experience in an adolescentís life.
Stress alone can trigger an urge to self-injure, primarily because stress reactions can be similar to other times that a child hurt themselves. In other words, stress from one cause can create an emotional memory of an entirely different situation. That memory can trigger more feelings and physical distress.
Dealing with Self-Injury
I canít adequately describe the fear, concern and misunderstandings that parents experience when their child self-injures. These feelings can drive parents to take desperate action based on the wrong assumptions. Parents should never assume that their child is self-injuring in order to manipulate people. It is not attention-seeking. It is a much deeper problem.
Parents should not assume self-injuring is a suicidal act. A suicidal act is more closely related to a desire to die. Self-injury is related to a desire to live without the emotional pain. These children do struggle with suicidal thoughts, feelings and desires. While there is a risk of suicidal behavior and suicide, self-injuring is not necessarily a suicidal act.
There are things you should keep in mind when you first encounter self-injuring behavior. If at all possible, parents should try to understand their childís self-injuring behavior. But do not suggest or describe a potential cause of the self-injury. You could make matters worse -- especially if you are wrong. Exploring and asking about the cause might also result in further self-injury or other dangerous, reckless, suicidal or violent behavior.
The self-injuring children are usually overwhelmed. Looking for a potential cause should be handled only with support of a qualified therapist who understands and treats self-injuring behavior. While you should not suggest a cause, you can try to understand the purpose of this behavior. This involvement may help you and your childís therapist.
Try to Understand the Purpose of a Childís Self-Injury
Self-injury may be a means to escape or avoid painful feelings and potential loss of self-control.
Asking a child to stop injuring them self is worth trying but becomes pointless and even counterproductive if the child does not believe they can stop. Asking your child to promise could become counterproductive. A broken promise might actually increase the severity of self-injury or the risk of suicide. Suicidal behavior is almost always associated with feeling helpless and hopeless. In most cases, self-harming behavior has the paradoxical effect that it gives a child a sense of control and hope.
Examples of Things You Should Avoid When Your Child is Self-Injuring
There are many things that a parent can do that may help. The best strategies are those that both your child and a therapist suggest. Parents can help their child feel grounded and gain a sense of control. This can help a child to avoid self-injury. However, it may not help if your child has been self-injuring for a long time or the pressure to self-injure is just too great.
Donít be disappointed or act frustrated if your child canít explain or make sense of their behavior and feelings. This is very common in the beginning of dealing with self-injury. Your child may not make a lot of sense. Their thought process can be driven more by emotions than logic. The thinking of a self-injuring child is often focused on impractical solutions to problems.
In some cases, the more an adolescent talks, the more upset they will get. It is OK to say you donít understand and to ask them to try to explain it again. It is also fine to ask a pointed question or do something that may help.
Examples of Things that May Help
Parents are really limited in what they can do to help a self-injuring child. The child may be facing a life-and-death issue. It is a strange reality indeed that a childís desire to live can be associated with self-injury. Even stranger, the actual idea of death is associated with a desire to stop self-injury.
There are so many other aspects that are difficult for parents. Parents will feel a tremendous responsibility while having little influence or ability to control what happens. Anxiety and frustration are common reactions. Parents will need to learn from their mistakes.
Most important, parents must remain aware and respond effectively to suicidal behavior. After that, it is important to support efforts by your child to find alternatives to self-injury. This may be difficult if your child has learned to use their self-injury to control you and get what they want. If this is the case, then you will definitely need a therapist. Your therapist should help you create a clear plan with rules and guidance for those times when you are being manipulated. There is a difference between a healthy request to deal with emotional problems and a child using self-injury to control a parent.
Finding Help for Self-Injuring Behavior
Hospitals are not usually a satisfactory place to get help for self-injuring behavior. By that we mean they are focused more on medical problems and life-threatening behavior such as suicide. Your child should obtain medical treatment if they have significantly injured themselves. Hospitals have advice nurses who can tell you if the child needs immediate medical care. Call a hospitalís main number and ask for an ďER Advice Nurse.Ē You should definitely call if you suspect or believe your child is suicidal.
In remote areas you may need to go to an urgent care facility or call a local physician. Clinics and hospitals may have referral information regarding professionals who work with self-injuring children, or they may refer you to other referral resources. It may be difficult to find a qualified counselor or therapist in a remote or rural area.
Hospitals are an important resource if your child is actively dangerous to him- or herself or others. Large hospitals that are not extremely busy may have mental health staff members that can provide an initial intervention. Smaller hospitals may not. In either size hospital you may encounter a physician or nursing staff member who has misguided information about self-injuring children.
Taking your child to a hospital may reduce the risk of suicide but probably will not reduce the risk of further self-injury. Do not assume your child will stop because you took them to a hospital and they promised they will not to do it again. They may just be telling you that because they donít want to go to the hospital again. This is why it is so important to obtain qualified consultation, evaluation and support from a mental health professional. You need a plan that is appropriate for your child.
Community mental health centers may be able to help. Unfortunately, many community mental centers are poorly funded. Lack of funding can make it difficult for them to retain qualified staff. Public agencies may be overwhelmed with people seeking services and have long waiting lists or restrict care to the most acutely ill. You need to be realistic about the difficulties and cost of finding appropriate help for your family. Keep trying until you find help that meets your childís needs. Do not be put off by insurance company gatekeepers or any other obstacle to adequate treatment. Be polite and persist.
Few professionals are willing to work with self-injuring children. The risk, liability and stress of working with these kids is very high. And in many cases, the children themselves are not the most challenging aspect of the situation. In many cases, at least one parent may be unstable, disruptive or manipulative. Some parents will actively undermine treatment and blame the therapist while denying their own dishonesty, lack of follow-through and unwillingness to control their own abusive or neglectful behavior.
Dated: December 30, 2007
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