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| Self-Injury: The Hidden Epidemic |
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| Feature Articles - Adolescents | ||||||||
| Written by Patrick L. DeChello PhD,MSW,LCSW,RPh | ||||||||
| Thursday, 26 May 2011 15:50 | ||||||||
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We are in the midst of a hidden epidemic – an epidemic so large that it is affecting youth in both the United States and the United Kingdom and in most of North America and Europe. Self-injury is a major health concern affecting more than 2 million adolescent girls in the United States, and at least 11,000 adolescent boys (National Mental Health Association, 2005). In Europe, 20 percent of adolescent females and 14 percent of adolescent males over 15-years-old are engaging in selfinjuring behaviors, according to Royal Berkshire Hospital in the United Kingdom, which reports an incidence ratio of nine females to one male. In fact, the United Kingdom has one of the highest rates in all of Europe, at 400 per 100,000 of the population. Current estimates are that there are at least 170,000 new cases each year that come into the hospital. Many self-injuring individuals never make it to the hospital because those who engage in this self-inflicted behavior often refuse to seek medical attention.Self-injury is a new drug of abuse – one that has the same effect on the brain as heroin, but it is legal, less expensive and always available in a never-ending supply. In three to four seconds, it accomplishes what Prozac takes three to four weeks to do. With its massive endorphin response and dramatic elevation of serotonin, the brain begins to crave it, with the urge becoming so strong that it is virtually impossible to stop using it without another alternative. Rarely heard of in the news or read about in the papers, selfinjury – often referred to as “New Age Anorexia” – is growing at an astounding rate of 10 percent annually worldwide. According to the World Health Organization, women have the highest rates of self-injury. For example, in Ireland, the rate is estimated to be 196 per 100,000 of the population. There are more than 10,000 identified cases seen in Irish hospitals each year.Those who self-injure are not the ones that get piercings or tattoos. They are difficult to identify, and are often: above average in intelligence; good to excellent students; and 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” (Sutton & Martinson, 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 incorrectly 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 & 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, followed by burning, there are many other self-injurious behaviors, including: cutting, skin-picking, hair pulling, burning, scalding, punching self, infecting oneself, scratching, scab picking, inserting objects into body, bruising or breaking bones, castration or any behaviors that cause immediate pain. Self-injury is a new drug of abuse – one that has the same effect on the brain as heroin, but it is legal, less expensive and always available in a never-ending supply. Self-injury is commonly done to: counteract suicidal feelings; alter a mood state, positive or negative; calm and/or remove overwhelming tension; self-punish; control anger, rage and dissociation; ground oneself to reality; physicalize what could not be verbalized; and counteract anxiety/depression. Self-injuring clients are predominantly Caucasian females from middle- to upper-middle class backgrounds. They tend to be well-educated perfectionists with average to above average intelligence, and under pressure to perform in their lives, with regard to grades, friends, physical appearance and activities. Self- injuring behaviors typically begin between ages 13 and 19, often continuing into mid-20s to early 30s. Often (but not always) self-injurers have experienced a trauma, such as physical or sexual abuse, and many have a history of psychiatric treatment. Several come from families with an alcoholic or drug-addicted parent. Additionally, concurrent eating disorders are common among self-injurers.Self-injurers use self-injuring behaviors as a way to cope with stress, and often lack the ability to regulate their moods by some other method (DeChello, 2008).The following are important statistics on self-injurers (DeChello, 2008): • most have had at least 50 previous acts of self-injury before seeking help; • 57 percent have overdosed on drugs at least once; • A third of them thought they would be dead within five years of the time they started self-injuring; • 50 percent have been hospitalized for self-injurious acts; • 14 percent of those hospitalized stated that the hospitalization actually helped; • 64 percent have been or currently were in psychotherapy; • 73 percent of those in outpatient therapy say it helps; and • as many as 90 percent report they were discouraged by their loved ones from expressing emotions, particularly anger and sadness as children. Most scientists believe self-injury is related to serotonin deficits. A drop in serotonin levels can result in depression and/or impulsive behavior. The endorphin release that is triggered by self-injury calms the individual, perpetuating a vicious cycle. Much work is needed to train, orient and sensitize medical, nursing and treatment professionals who often downplay or ignore self-injuring behaviors. As previously stated, only 14 percent of those who selfinjure 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.The first step in recovery for the self-injurer is “admitting to the behavior.” When a person admits to a treater 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; and ultimately, may force the client back into his or her shell, thus 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, clients 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. The role of the supervisor cannot be stated strongly enough. The clinical supervisor’s role is to: monitor the treatment; guide the clinician; and identify transferences and counter-transferences. This is a behavior which is very capable of putting many treatment professionals into a state of both conscious and unconscious turmoil. What is in the best interest of the client, truly becomes a key question that the supervisor can explore with the treatment provider. The supervisor helps determine a reasonable standard of practice which is in line with generally accepted treatment methodologies. This, in turn, provides legal safety which allows for some comfort when dealing with these potentially lethal individuals. 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. Bloodborne pathogen training also should be considered, in order to limit a client’s own exposure, as well as that of others who might be exposed to his or her instruments or body fluids, thereby limiting the spread of infectious diseases such as, HIV or hepatitis. Family intervention is usually critical since the family is often either at the root of the trauma that precipitated the behavior or is exacerbating the behavior, leading to 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 may actually worsen the situation. If the plan is for the selfinjurer to stay in his or her home with his or her family, then it is critical that the family be part of the intervention. The roles in the family designed to maintain a homeostasis, often parallel those in a substance abuse family. These roles include the enabler, codependents, mascot (Clown), the hero, the lost child and the scapegoat. The dynamics of the family should be examined and integrated into a treatment plan, thus planning for success. 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. Since children and adolescents are the principle group engaging in this behavior, there is a need for education in the schools aimed at primary and secondary prevention, first-aid and disease prevention. In order to reach these youth, each school could offer harm-reduction classes around selfinjury. Furthermore, children should attend a class on conflict resolution to provide them with further skills to enable them to properly deal with life stressors. Research also demonstrates that today’s youth are also attracted to alternative interventions such as yoga, REIKI and stress-reduction training.The parallels with chemical dependency treatment are many. Successful treatment requires the empowerment of the user and a desire and commitment to regaining control over his or her life. 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 life stressors, which could lead to suicide as a primary alternative option. The substance abuse treatment community is the most appropriate core group to work with these individuals, given that it is accustomed to working with addictions as coping mechanisms, and has an arsenal of treatment methodologies that work, such as cognitive behavioral therapies, Dialectical Behavioral Therapy (DBT), reality therapies and many others. Additionally, the substance treatment community is accustomed to treating addictions with harm reduction philosophies that do not advocate strict abstinence. It is time that we in the treatment community take our heads out of the sand and deal head-on with this increasing epidemic. Our youth are depending on us and services are lacking. 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. I call on our policy makers to be proactive and provide training, treatment and programming for this ever expanding group. How many will have to die; how much will this epidemic grow; how much disease will have to be spread; how much decay of morals in our societies will have to occur before we address this hidden epidemic?
References Alderman, T. (1997). The Scarred Soul: Understanding and Ending Self-Inflicted Violence. Oakland: New Harbinger.Babiker, Gloria and Arnold, Lois. (1999).The Language of Injury. Leicester, BPS Books, U.K.Barnes, R. (1985). Women and self-injury. International Journal of Women’s Studies, 8(5), 465-475.Coccaro, E. F., Kavoussi, R. J., & Hauger, R. L. (1997b). Serotonin function and antiaggressive response to fluoxetine: a pilot study. Biological Psychiatry, 42(7), 546-552.DeChello, Patrick.(2010). The Assessment, Diagnosis and Treatment of Personality Disorder, 3rd edition. D & S Associates, Middlefield, Connecticut.DeChello, Patrick (2008). Understanding Self-Injury. D & S Associates, Middlefield, ConnecticutDiClemente, R., Ponton, L., & Hartley, D. (1991). Prevalence and correlates of cutting behavior: risk for HIV transmission. Journal of the American Academy of Child and Adolescent Psychiatry, 30 (5), 735-739.Favaro, A. & Santonastaso, P. (1998). Impulsive and compulsive self-injurious behavior in bulimia nervosa: prevalence and psychological correlates. Journal of Nervous and Mental Disease, 186(3), 157-65.Favazza, A. R. (1998). The coming of age of self-mutilation. Journal of Nervous and Mental Disease, 186(5), 259-68.Favazza, A. R. (1996). Bodies Under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry, 2nd ed. Baltimore: The Johns Hopkins University Press.Hawton, K., Arensman, E., Townsend, E., Bremner, S., Feldman, E., Goldney, R., Gunnell, D., Hazell, P., van Heeringen, K., House, A., Owens, D., Safinosky, I., & Traskman-Bendz, L. (1998). Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. British Medical Journal 317(7156), 441-7.Kehrberg, C. (1997). Self-mutilating behavior. Journal of Child and Adolescent Psychiatric Nursing, 10(3), 35-40.Linehan, M., Arstron H.E. et al. (1991). Cognitive-behavioral treatment of chemically parasuicidal borderline patients. Archives of General Psychiatry 48: 1060.Linehan, M. (1993). Cognitive-behavioral treatment for borderline personality disorder. New York: Guilford Press. Martinson, Deborah. (2003). Because I Hurt. How To Books, United Kingdom 2003.National Health Service, National Institute For Health and Clinical Excellence (2005). New Guidelines set to improve identification, diagnosis and treatment of obsessive-compulsive disorder in children and adults. London, U.K. Press Release Nov. 23, 2005.National Suicide Research Foundation (2002).“National Parasuicide Registry Ireland Annual Report 2002” NSRF, Cork, Ireland. Solomon, Y. & Farrand, J. (1996). “Why don’t you do it properly?” Young women who selfinjure. Journal of Adolescence, 19(2), 111-119.Sutton, Jan (2005). Healing The Hurt Within: Understanding Self-Injury and Self-Harm, and Heal the Emotional Wounds. How To Books, United Kingdom. Sutton, Jan (2003). Because I Hurt. How To Books, United Kingdom.Van der Kolk, Perry & Herman (1991). Study on Effects of Trauma on Self-Mutilating Behavior. Trauma Clinic, HRI Hospital, Brookline, MA. Van de Kolk B.A., Hostetler, A. Herron, N. & Fisler, R.E. (1994).Trauma and the Development of Borderline Personality. National Library of Medicine. Psychiatric Clinic North America, Dec;17(4):715-730Van der Kolk, Perry &Herman. (1991). Study on Effects of Trauma on Self-Mutilating Behavior. Trauma Clinic, HRI Hospital, Brookline, MA.
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Patrick DeChello PhD, LCSW, MSW, RPH is an internationally recognized clinical social worker, clinical psychologist, Hypnotherapist and chemical dependency treatment specialist with more than 30 years of experience. He is the author of 29 books and numerous articles in the mental health and chemical dependency fields and is the founder and senior partner of D & S Associates, an international training and consulting company serving the mental health and substance abuse treatment fields.