We are in the midst of a hidden epidemic. An epidemic so large that it is affecting our youth in both the United States and the United Kingdom, in most of North America and in Europe. This hidden epidemic is a major health concern affecting over 2 million adolescent girls in the United States or 1 in every 200 girls over the age of 13. . While girls generally practice these behaviors, it also is evident in at least 11 thousand boys a year as well in the United States alone. (National Mental Health Association, 2005).
The hidden epidemic is a new drug of abuse. A drug that has the same effect on the brain as heroin, but it is legal, less expensive, is always available and there is a never ending supply. It does in the brain what heroin does in 6 minutes and Prozac takes 3-4 weeks to do, but it does it in 3-4 seconds. With its massive endorphin response and dramatic elevation of dopamine and serotonin, the brain begins to crave it and the urge to have it is so strong that it is virtually impossible to stop using it without another alternative.
This epidemic is growing at an astounding rate of 10% annually worldwide. Often referred to as the “New Age Anorexia’ the drug I am speaking of is known not as a drug, but as self-injury.
According to the World Health Organization, the highest rates are amongst women regardless of age. The female use of it consistently outnumbers the number of men who do it. In Ireland, the rate is estimated to be 196 per 100,000 of the population. There are over 10,000 identified cases seen in Irish hospitals each year.
Those that self-injure are not the ones that get piercings or tattoos. They are difficult to identify. They are often:
1. Above average in intelligence
2. Good to excellent students
3. Rarely participate in activities that require a change of clothing.
Self-injury as a coping mechanism, is highly effective.
“Self injury is an expression of acute psychological distress. It is an act done to oneself, by oneself, with the intention of helping oneself rather than killing oneself. Paradoxically, damage is done to the body in an attempt to preserve the integrity of the mind.” Jan Sutton & Deb Martinson –Secret Shame, 2003
The crisis we face as a field is the lack of understanding on the part of treatment providers, their over-reaction and their wrongful assumption that self-injury is an attempt at suicide. On the contrary, self-injury is the antithesis of suicide.
Many wrongly assume 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)
Suicide versus Self-Injury
• Self-injury is distinct from suicide.
• A person who attempts suicide seeks to end all feelings.
• A person that self-injures seeks to feel better.
• Suicide behaviors are less frequent and do not provide relief rather they communicate.
Self-injury is a deliberate act used to alter mood by inflicting physical violence onto oneself. While cutting is the most common form of self-injury, there are many other self-injurious behaviors. For example:
• Punching self •
• Scab picking
• Inserting objects into body
• Bruising or breaking bones
• Any behaviors that cause immediate pain.
• *most common
Self-injury is commonly done to:
• Counteract Suicidal Feelings
• Alter a mood state positive or negative
• To calm & remove overwhelming tension
• To self-punish
• To control anger, rage & dissociation
• To ground oneself to reality
• To physicalize what could not be verbalized
• Counteract anxiety/depression
The Demographic Characteristics of the self injurer are: (DeChello, Understanding Self-Injury, 2008)
1. Predominantly female
2. Start self-injuring between ages 13-19, and often continue into their mid-20’s to early 30’s but have self injured since in their teens.
3. They are predominantly Caucasian
4. Are extremely perfectionistic
5. Under pressure to perform in their lives, grades, friends, looks, outside activities etc.
6. Commonly are middle to upper-middle class
7. Average to high-average intelligence
8. Are well educated
9. Often a background of physical or sexual abuse or trauma though not always
10. Often come from a family with an alcoholic or drug addicted parent
11. Often have a concurrent eating disorder.
12. They use it as a way to cope with stress
13. They often lack the ability to regulate their mood by some other method.
14. Often they have a history of having been in psychiatric treatment.
Important Statistics (DeChello, Understanding Self-Injury, 2008)
• Most have had at least 50 previous acts of self-injury before seeking help.
• 57% have taken a drug overdose at least once.
• A third of them thought they would be dead within 5 years of the time they started self- injuring.
• 50% have been hospitalized for self-injurious acts
• 14% of those hospitalized stated that the hospitalization actually helped.
• 64% have been or currently were in psychotherapy
• 73% of those in outpatient therapy say it helps.
• As many as 90% report that they were discouraged by their loved ones from expressing emotions, particularly anger and sadness as children.
Why do people deliberately injure themselves?
“Self-mutilation is a desperate attempt to have some control over unbearable feelings. When a teen or young adult has not learned healthy ways of managing these intense emotions, they turn to pain as a way to blot out the emotional pain or gain a sense of control over the pain that they feel. In a strange way, they are really trying to not hurt themselves –they are trying to protect themselves from something even more painful than the physical pain.” Dr. Margaret Paul
Neurochemistry & Self-Injury –
• Scientist believe SI is related to Serotonin deficits. –
• Serotonin levels drop -> leads to depression and/or impulsive aggressive behavior -> Self Injury ->endorphin release -> calm
• This becomes a vicious cycle.
Much work needs to be accomplished to train, orient and sensitize medical, nursing, and treatment professionals who often downplay or ignore the behaviors. As previously stated, only 14% of those who self-injure who were interviewed by myself (n=200) found hospitalization to be effective. This is handled much more effectively outside of the hospital. If professionals could get past their fears of suicide with these individuals, the rate of successful intervention would increase dramatically. In my opinion the fear of suicide often results in inappropriate hospitalization. In reality by doing so we are often treating the clinician.
The first step in recovery for the self-injurer is “admitting to the behavior.” When a person admits to a clinician that they engage in this behavior, there is no greater sign of trust. This trust is fragile and can easily be destroyed if the treating clinician over reacts. Ultimately, forcing the client back into their shell and ending hope of useful intervention.
A Harm Reduction Model where the objective is not to condone this behavior, but to acknowledge the importance of it in the day-to-day life of the self-injurer can be highly effective. Trying to take away the behavior without alternatives may lead to continued self-injury or suicide. If this is their primary coping mechanism, they need to explore new coping mechanisms before being able to let go of old ones.
Because of the potential inherent dangers associated with these behaviors, clinical supervision is necessary to monitor treatment and to aid the clinician in order to be able to maintain objectivity with this client.
While self-injury is often an alternative to suicide, self-injurers may cut too deep. Individuals engaged in these behaviors should be trained in general first aid and know how to deal with a medical emergency. First aid training should be part of the treatment protocol.
Family intervention is usually critical since the family is often either at the root of the trauma that precipitated the behavior to begin with or often exacerbated its continuance. Families tend to have a strong reaction when they first hear that a loved one is engaging in these types of behaviors. Often acting out of fear, guilt and anger, families can in fact worsen the situation. If the plan is for the self-injurer to stay in their home with their family, the family must be part of the intervention if success is to be a possibility.
Self-injury is a drug and becomes habit forming. It requires the intervention of a knowledgeable clinician and sometimes non-conventional interventions that meet the client’s needs without causing further damage.
The parallels with Chemical Dependency Treatment are many. Successful treatment requires the empowerment of the user and their desire and commitment to regaining control over their lives. The choice to end the behavior or limit its use lies strictly with the user. Limiting the behavior through development of alternate behaviors is the key to success. Simply telling the addict to stop the behavior never works. Forced treatment and abstinence only based approaches leave the self-injurer with few options to deal with their life stressors. Therefore their primary alternative option may become suicide.
The substance abuse treatment communities are the most appropriate core group to work with these individuals. They are accustomed to working with addictions as coping mechanisms and have the arsenal of treatment methodologies that work such as cognitive behavioral therapies, Dialectical Behavioral Therapy (DBT), Reality therapies and many others. The substance treatment community is accustomed to treating addictions with Harm Reduction philosophies that do not advocate strict abstinence. It is time that the treatment communities take our heads out of the sand and deal head-on with this increasing epidemic.
This is an area that must be addressed before it spirals out of control. Ignoring the problem will not make it go away. Self-injury can lead to death, disease and destruction to the future fabric of our societies, our youth. I call on our policy makers to be proactive and provide training, treatment and programming for this ever expanding group.
Patrick DeChello Ph.D., LCSW, MSW, RPH is an internationally recognized clinical social worker, clinical psychologist, Hypnotherapist and chemical dependency treatment specialist with well over 30 years of experience and author of 29 books and numerous articles in the mental health and chemical dependency fields
His books and presentations have a reputation for being clear, humorous, pragmatic and cutting edge. His clinical skills and vast knowledge base make both his writings and presentations enjoyable and highly educational.