This is the handout I am providing for the November 2, 2010 Arte Sana Nuestras Voces / Our Voices National Conference on self-injury. If you need a MS Word copy, let me know.
Cutting Away at Emotional Pain Handout
History
- 1938–Karl Menninger wrote Man Against Himself delineating self-injury separate from suicidal behavior
- 1996-Princess Diana volunteered that she was a cutter
Self-mutilation
- A self-injurious behavior with no intention of suicide and is distinct from sanctioned piercings, etc.
DSM-V
- Non-Suicidal Self-Injury is proposed as a new entry in the upcoming DSM.
Three categories
- Superficial (considered today and below)
o Common form seen in adolescents and includes cutting (most common), skin pricking, severe nail biting, stabbing, scratching, burning or scalding, hair pulling, chafing and interfering w/ wound healing.
o Common items used include pencil tips, paper clips, pins, glass, razors, box cutters, scissors and drink can tabs.
o Areas commonly cut are wrists, arms, ankles, calves, inner thighs, belly, brassier line, armpits and feet.
- Stereotypic
o Generally seen in autistics, individuals with intellectual disability or Tourette’s syndrome
o Common behaviors are rhythmic hitting oneself, head banging, orifice digging, throat and eye gouging, self-biting and joint dislocation
- Major
o Commonly seen in those that are psychotic or intoxicated
o Extreme nature resulting in significant tissue damage
o Self-destruction includes such things as eye enucleation, genital mutilation or castration, limb amputations and bone breaking
Etiology (superficial)
- Much research is yet to be done to understand this complex issue
- Best predictors of self injuring
o Childhood sexual abuse
o Family violence
o Loss of a parent or guardian
o Childhood illness
o History of substance abuse
o Another family member self-injures
o Poor mood regulation
o Eating disorders such as anorexia or bulimia
o Trauma as a child – trauma severity is associated with injury severity
o Previously stayed on the street
- Motivations
o Still not understood, but not masochistic (pleasure of pain is not sought)
o Reduced coping skills to manage the situation or perceived stressors
o Intolerable & intense levels of anxiety and tension or depression or loneliness
o To feel pain on the outside, not the inside (physical / emotional tradeoff)
o To overcome numbness, to feel something, to cut matter so they “matter” – I’m real
o Way to gain control over urges for sex or death
o Aggression turned inward (body not perceived as self, but as an object)
o Self-punishment or an act of religious atonement
o To simulate feelings of past physical or sexual abuse, to unconsciously reconnect to the abuser
o A cry for help in a nonverbal way – confronting an injustice – an un-redressed grievance
o Way to self-medicate – pain leads to endorphins being released
- The Two Root Characteristics of all Self-Mutilators
o 1) A feeling of mental disintegration where one has an inability to think
o 2 ) A feeling of rage that can’t be expressed, or even consciously perceived, towards a powerful figure or figures in their life, commonly a parent – one is afraid to argue or articulate – no outlet – fear of punishment or disapproval (Levenkron)
o Physical pain or sight of one’s own blood is a way to drown out one of these two feelings
Parental Factors
- Parent could be fragile and child is afraid to harm their parent by expressing anger
- Parent could be neglectful or abusive or controlling or incestuous
- Parent could have a financial stress, alcohol issues, emotional distress, marital distress, death
- Not about blame, everyone is doing the best they can
Prevalence
- Adult population prevalence is 4%, clinical adult population up to 21%
- Adolescent population prevalence is anywhere from 14 to 39%, clinical adolescent is 40-61%
- College student prevalence is 32%
- Levenkron estimates 1 in 50 adolescents
- LGBT youth at Youth First Texas rates were 36%
- Among homeless youth, 69% self injure
Premeditative or compulsive
- 19% think about it days or hours ahead of time
- 27% thought of it 6 minutes or up to an hour ahead of time
- 55% thought of it less than five minutes before the action
- Levenkron ultimately considers it to be compulsive from a trancelike state
Sex, Class, Rural
- Three large studies show no sex association though Levenkron says mostly females cut
- No class associations
- No rural/urban associations
Counselor
- Must be exceedingly empathetic and not punitive or repulsed
- Need to take “boy scout/girl scout” stance and see past the frightening self-infliction
- Often requires intervention, referrals to physician, monitoring of wounds
- Must become desensitized and sit with the client in their pain/rage/despair, get close to it
- Must be informed so as to inform the client with straight facts
- Need to understand the client’s pain, listen to their story and value them, give them voice
- Break identification with being a cutter toward being someone who once cut – illness is not identity
- Basic task: form a relationship based on trust that encourages dependency and healthy attachment
- Timberlawn in Dallas has a treatment center for cutting
- There may be hereditary factors or predispositions, but they are not a “sentence”
Reference:
- Cutting: Understanding and Overcoming Self-Mutilation, Steven Levenkron
- For this handout, literature review and Dallas Voice article that led to this panel
o (See Renee-Baker / Self-Injury Topics)
Acknowledgment:
- I would like to thank Melina Castillo of ARTE SANA for suggesting the idea for this panel!
