We’ve become used to adolescents today using their bodies in a wide range of more or less painful ways to express who they are–piercing, tattooing, skin bronzing, extreme sports. But deliberate self-injury is an activity that seems especially scary and inexplicable both to parents and many therapists, even in a world that’s relatively tolerant of other forms of branding and mutilation.
It’s estimated that as much as 4 percent of the general population engages in self-injurious behavior, and that, in some high schools, a whopping 14 percent of the students do. The first incident often occurs in early adolescence, and the behavior may continue through college and well into adulthood. Approximately 20 percent of individuals of all ages who seek psychiatric or psychological help report engaging in self-injury; among adolescent and emerging-adult females, this percentage is likely much higher.
Of all of the types of self-harm, cutting is a curiously female form of expression, and perhaps the most distinctive gender-based problem therapists encounter. For adolescent girls, it’s frequently related to temporary stressors, and not deep, underlying psychopathology. All kinds of adolescent girls cut themselves—those with histories of trauma and disrupted parental care, as well as those with more transient relationship and developmental difficulties.
However mystifying cutting may appear at first glance as a psychological symptom, we now know that girls engage in this behavior to find relief for painful states of consciousness, so they can cope with other aspects of living. Girls resort to cutting to cope with emotional tension, enabling them to control and regulate overwhelming affect. By transforming emotional pain into physical pain, and releasing it in this manner, girls get momentary relief from the internal pressure.
Recent observations from biological theory hold that self-mutilation can become something of an addictive drug because cutting increases levels of endogenous opiates in the body, which results in a brief feeling of being high. If girls aren’t learning other strategies for coping, they’ll repeatedly return to self-harm to get another shot of endorphins, which generate a sense of release, calm, and pleasure. Since endogenous opiates are natural painkillers, girls describe feeling little if any physical pain when they’re harming themselves, even when they’re inflicting severe injury.
It’s likely that girls who self-harm are capable of extreme dissociative states. They report being completely cut off at the time of self-injury, describing something like, “It isn’t me doing it. I’m watching it being done.” Psychiatrist Judith Herman has theorized that the physical jolt caused by self-harm–for instance, the sight of bright-red blood–has the power to break a dissociative trance.
How to Help
Researchers and therapists agree that one of the most therapeutically relevant characteristics of the self-harming adolescent is a difficulty verbalizing (and feeling in control of) emotions and needs. Therefore, therapy must help girls communicate effectively. In the context of the therapeutic relationship, girls can develop the ability to articulate emotions and needs, and learn to use alternative behaviors to cope with their feelings and communicate about them.
Therapy for self-harm integrates the best features of cognitive-behavioral, narrative, interpersonal, and family-systems therapy. It’s vital to emphasize that effective therapy must deal with feelings. Girls who self-harm aren’t emotionally numb, cut off, or dead, although they may appear to be, but they have trouble finding the language to put their internal experience into words.
To find other means of expression than self-harm, girls must develop quite a long list of new experiences, strategies, and skills:
– Safety. Optimally, girls should have more safe connections than just the one in therapy, but it’s a fine place to start. They benefit enormously from experiencing empathy and developing a trusting connection to someone who can listen hard, has reasonable boundaries, and sets fair expectations.
– Language skills. Most of all, girls must learn to talk about themselves and to modulate their feelings and integrate them into everyday life. Instead of ridding themselves of affect through physical pain or disconnecting from it through dissociation, self-harmers must learn the skills of containment and verbal expression.
– Grounding. Girls can learn how to stay present and become less dissociative. To do so, they need to practice staying oriented in the present, staying in their bodies, and knowing, naming, and regulating unbearable affective states when they’re in stressful situations.
– Positive substitution. When girls feel upset, they’re unable to recall positive emotions. To offset this tendency, you can help them make a “Rainy Day Box” in which they put ticket stubs, accounts of good times, happy photos, letters, and so forth. Then when they feel the internal pressure building, they can go through these memories, substituting the pleasant associations for their overwhelming, negative feelings.
– Distraction. Some girls find they can distract themselves enough to get through a crisis without self-harming. You may be able to help girls develop rituals that they’ll follow before they “allow” themselves to self-harm. Paradoxically, by giving themselves permission to self-harm but following rituals before they do, girls can get the sense of control they need to overcome the urge to hurt themselves. Other distractions include activities that are incompatible with self-harm, such as contacting someone, taking a bubble bath, or making dinner. Similarly, relaxation exercises may provide a form of distraction. The point is for them to focus on an activity that isn’t self-injuring.
– Recognizing and avoiding triggers. By recording all the situations, thoughts, and feelings that lead up to an episode of self-harm, girls can figure out what their self-harm triggers are. Then they have a better shot at avoiding or minimizing the situations that increase their vulnerability. They also have something useful to talk about in therapy, because these triggers tend to be connected to the major developmental issues faced by adolescents–identity, loneliness, hurt, peers, family, and worries about the future.
– Improving self-care skills. Girls who harm themselves are disconnected not only from their feelings of pain and distress, but also from normal bodily cues related to hunger, thirst, fatigue, cold, illness, or hygiene. Therapists and families have to work together to support girls in taking better care of themselves by eating well, getting enough rest, staying in bed when unwell, dressing for the weather, and attending to personal cleanliness.
– Relationships. While girls do get better when they have a therapist to talk to, we need to help them develop other productive and nurturing relationships with family, friends, teachers, and their communities.
Ultimately, it’s our job to support girls in translating the symbolism of self-harm into words and to hear them tenderly. By this means, we can help them learn to recognize overwhelming feelings and express them in ways that don’t harm themselves or others.
Martha Straus, PhD, a professor in the Department of Clinical Psychology at Antioch University New England, is the author of No-Talk Therapy for Children and Adolescents, Adolescent Girls in Crisis, and Treating Traumatized Adolescents: Development, Attachment, and the Therapeutic Relationship.